Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


The patient presented to the emergency department (ED) with worsening exertional shortness of breath. She had gone to the ED previously. She was treated with steroids and albuterol without improvement. She did not have a fever.
The patient was unable to perform activities of daily living without developing dyspnea. She did not have any orthopnea. She uses a continuous positive airway pressure (CPAP) machine at night due to sleep apnea. She has intermittent chest tightness and intermittent productive cough. The patient also complained of intermittent palpitations since the weekend lasting a few seconds.
The patient has baseline lower extremity (LE) edema. Her past medical history revealed asthma, obstructive sleep apnea (OSA), hypothyroidism, gastroesophageal reflux disease (GERD), and pulmonary hypertension (HTN) that resolved per the last echocardiogram.
Her physical examination revealed a blood pressure (BP) of 138/96, heart rate (HR) 73, temperature 36.4 degrees Celsius, and oxygen saturation (O2 sat) 97%. Her physical examination revealed morbid obesity. She was visibly tachypneic after ambulation in the ED without the use of accessory muscles. There was a normal lung exam, an unremarkable cardiac exam, and a normal abdominal exam. She had trace LE edema.
The troponin was normal. D-dimer was less than 202, white blood cell count (WBC) 14.9 and brain (or B-type) natriuretic peptide (BNP) 14. A chest x-ray (CXR) was normal. Coronavirus (COVID) testing was negative.
A chest computed tomography (CT) scan revealed mild subsegmental atelectasis air trapping at the lower aspects of the right middle lobe and lingula, and at the lung bases. It was interpreted as "findings related to smoking or smoke exposure, including mild emphysema and hyperinflation of the lungs."
The patient was admitted to the hospital for further evaluation of her dyspnea. The patient was consulted by cardiology. They noted that the patient had an episode of paroxysmal atrial fibrillation (afib) after knee replacement surgery. Serial troponin and an echocardiogram were recommended. Because of intermittent palpitations, ambulatory monitoring after discharge was recommended. The patient underwent an echocardiogram which revealed a normal ejection fraction, mild tricuspid regurgitation (TR). Her serial troponin was normal. She was not hypoxic. Her condition remained stable. Her diagnosis was mild persistent asthma. She was discharged home.
At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was not medically necessary for this patient.
This patient had a history of asthma and presented with worsening shortness of breath. She was admitted for work up for possible other causes for her dyspnea, such as pulmonary emboli or congestive heart failure (CHF). The work up was negative. The patient had evidence of emphysema on her CT scan and she also suffered from OSA. Otherwise, the work up was negative. Her vital signs were unremarkable. She was treated for her asthma with inhalers.
The patient's condition and level of care provided did not meet inpatient admission criteria. Care could have been provided at a lower level.
 Per the first reference: "After weighing the quality of evidence and balancing the desirable and undesirable effects, the guideline panel made the following recommendations: 1) a strong recommendation for the use of long-acting beta () 2-agonist (LABA)/long-acting muscarinic antagonist (LAMA) combination therapy over LABA or LAMA monotherapy in patients with chronic obstructive pulmonary disease (COPD) and dyspnea or exercise intolerance; 2) a conditional recommendation for the use of triple therapy with inhaled corticosteroids (ICS)/LABA/LAMA over dual therapy with LABA/LAMA in patients with COPD and dyspnea or exercise intolerance who have experienced one or more exacerbations in the past year; 3) a conditional recommendation for ICS withdrawal for patients with COPD receiving triple therapy (ICS/LABA/LAMA) if the patient has had no exacerbations in the past year; 4) no recommendation for or against ICS as an additive therapy to long-acting bronchodilators in patients with COPD and blood eosinophilia, except for those patients with a history of one or more exacerbations in the past year requiring antibiotics or oral steroids or hospitalization, for whom ICS is conditionally recommended as an additive therapy; 5) a conditional recommendation against the use of maintenance oral corticosteroids in patients with COPD and a history of severe and frequent exacerbations; and 6) a conditional recommendation for opioid-based therapy in patients with COPD who experience advanced refractory dyspnea despite otherwise optimal therapy. "