Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma exacerbation.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is a female patient with morbid obesity, history of asthma, bipolar disorder and history of low back pain. She presented to the Emergency Department (ED) with chest pain and low back pain of two weeks duration. She also complained of some chest tightness, productive cough with yellow sputum, and dyspnea. The patient had taken her inhalers at home but did not have much relief, for which she presented to the ED. Her vital signs at ED presentation were: temperature 37.1, blood pressure 148/79, heart rate 75, respiratory rate 20, and oxygen saturation 99%. Her lung exam revealed decreased air entry; there were no adventitious sounds. Her cardiovascular exam was normal. No increased work of breathing was noted. The patient was treated with intravenous (IV) steroids, bronchodilator nebulizers, and non-steroidal pain medications. Her electrocardiogram (EKG) showed normal sinus rhythm (NSR); there were no acute changes. The patient's troponin level and D-dimer levels were within normal limits. The patient's chest X-ray showed cardiomegaly. The patient's venous blood gas (VBG) levels were: potential of hydrogen (pH) 7.39, partial pressure of carbon dioxide (pCO2) 42, and partial pressure of oxygen (pO2) 40. She was admitted to the hospital for treatment of asthma exacerbation. 

The patient was placed on bi-level positive airway pressure (BiPAP) 16/5 with fraction of inspired oxygen (FiO2) 35%. As per the history and physical (H&P), the patient's vital signs were: temperature 97, heart rate 94, respiratory rate 20, blood pressure 127/50 and oxygen saturations 97 %. She had bilateral wheezing on lung exam and lower extremity edema. On day 2 of admission, the patient's vital signs were: temperature 97.2, heart rate 92, respiratory rate 16, blood pressure 104/59, respiratory rate 16 and oxygen saturation 100%. She had decreased air entry on lung exam; minimal wheeze present. She was given one dose of IV Lasix. Her echocardiogram showed left ventricular ejection fraction (LVEF) > 50%; there was no right ventricular (RV) strain or dilatation. She was evaluated by pulmonary who had recommended weaning from BiPAP.

Based on the review of the medical record and literature, inpatient hospital admission was not medically necessary for this patient. The patient could have been placed in observation status while diagnostic testing and treatment were initiated. As per literature, patients can be kept in observation status for up to 48 hours before decision to admit is made. In this case, the patient was afebrile and hemodynamically (HD) stable. The patient was not hypoxic and was not retaining carbon dioxide (CO2). The patient's peak expiratory flow (PEF) was 400 as per the H&P. The patient's lung exam showed minimal wheezing. The patient's white blood cell (WBC) count was normal. There was no clinical finding of pneumonia or pleural effusion or pneumothorax (PTX) for this patient. The patient's echocardiogram was normal. There was no evidence of cardiac ischemia or myocardial infarction (MI) for this patient. This patient could have been discharged after a period under observation when diagnostic testing and treatment could have been pursued. The patient was afebrile and hemodynamically stable. The patient could have been discharged home on oral steroids, bronchodilator (BD) and oral antibiotics if clinically indicated. This patient could have been sent home on nocturnal BiPAP if needed. However, there was no clinical indication for BiPAP, as this patient was not hypoxic and was not retaining CO2. 

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial should be upheld.