Appeal type: Medical necessity
Decision: Upheld

Respiratory System/Asthma 
Inpatient Hospital

Diagnosis: Respiratory System/Asthma/Acute Asthma Exacerbation
Treatment: Inpatient Hospital Admission

This case involves a woman who presented to the hospital with a cough, shortness of breath and wheezing. She has a history of asthma with multiple admissions and uses Symbicort at home. The patient had a sudden onset of cough that was not associated with sputum production. She continues to smoke cigarettes; symptoms were triggered by smoking. She ran out of her inhaler two days before this presentation, as well.
Vital signs appeared relatively stable except for tachycardia at 128 beats per minute (bpm). On her lung exam, she had scattered crackles and wheezes with mild distress, using accessory muscles.

The medical team continued the DuoNebs and corticosteroids. They also ordered serial liver function tests (LFTs) and an ultrasound of the abdomen. It was suspected the liver enzymes were elevated due to alcohol use. The Clinical Institute Withdrawal Assessment (CIWA) score was calculated at 0.

On hospital day 2, the asthma exacerbation was deemed to be improving, the intravenous (IV) steroids were converted to oral, and the patient was continued on DuoNebs. She maintained an oxygen saturation at 97% on room air. The hepatobiliary iminodiacetic acid (HIDA) scan was still pending. Per the medical team, the patient was experiencing right upper quadrant pain and had developed a urinary tract infection (UTI). This was treated with oral Bactrim for 7 days. The viral hepatitis panel was unremarkable.

I fully uphold the health plan's determination of medical necessity.

No. The inpatient hospital admission was not warranted in this case.
Based on the provided documentation, there is no evidence that treatment under inpatient status was necessary for this presentation. The patient presented with a cough and was deemed to be experiencing an asthma exacerbation. She maintained excellent oxygen saturations, and no secondary lung conditions were exacerbating underlying asthma. There was no infiltrate on the chest x-ray. There are no documented peak flows to suggest severely obstructive disease. The patient did not require noninvasive or invasive ventilation to support her respiratory status. Treatment of asthma included corticosteroids and bronchodilators, and the patient's condition improved.
Based on evaluation in the Emergency Department, the patient was incidentally found to have elevated liver enzymes. The right upper quadrant ultrasound revealed cholelithiasis, and then it took another two days to obtain a HIDA scan, which was negative. The liver enzymes gradually resolved without any significant interventions. Even when clinically evident, evaluation treatment of acute cholecystitis can be managed under observation care, typically with laparoscopic cholecystectomy. Patients are typically released from the hospital within 24 hours in stable condition. This patient did not require surgical intervention. The liver enzymes were only mildly elevated, without clear evidence of obstructive biliary disease. There is no documentation to suggest the patient was severely dehydrated. There is no evidence of synthetic dysfunction based on laboratory studies.
The patient was primarily admitted for an asthma exacerbation, which proved to be mild and did not require inpatient treatment. Similarly, evaluation and treatment for cholelithiasis and the treatment of the UTI did not satisfy the criteria for inpatient admission. I have included medical literature and support for this decision. I have also reviewed the Milliman criteria for this case, and clinical indications for admission to an inpatient level of care are not satisfied.
Finally, the patient was diagnosed with a urinary tract infection without evidence of nephritis or sepsis to warrant an inpatient admission.
In summary, the patient's conditions were mild and did not require an inpatient admission.