Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath
Treatment: Inpatient Stay
The insurer denied the Inpatient Stay.
The denial is upheld.

The patient is a female with a past medical history significant for hypertension, hyperlipidemia, gastroesophageal reflux disease (GERD), asthma, and depression who presented to the hospital with complaints of cough and shortness of breath.
It was reported that the patient was evaluated for the same symptoms prior to this admission and at that time a chest x-ray was performed that demonstrated patchy infiltrates suggestive of right middle lobe pneumonia. She was given a prescription for Augmentin and Zithromax and was discharged home. Two days later she developed wheezing and was prescribed an Albuterol inhaler. The patient stated that she did not experience improvement with her outpatient treatment and was advised to return to the emergency department and repeat a chest x-ray. The repeat imaging was negative for any infiltrates, so antibiotics were discontinued. At the time of admission, she was afebrile. Pulse rate was 78 beats per minute (bpm), respiratory rate 18 breaths per minute, blood pressure 129-171/88-107. Oxygen saturation was 97-100% on room air.
The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), and carotid bruits. Lungs exam revealed wheezing. The patient had a regular rate and rhythm, without murmurs, rubs, or gallops. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. The rest of the physical exam was unremarkable. Laboratory evaluation revealed that white blood cell count was 4.1, hemoglobin 13.2, hematocrit 40.3, platelets 256. Sodium was 140, potassium 4.0, chloride 104, bicarbonate 26, blood urea nitrogen (BUN) 12, creatinine 1.0, glucose 84. During the hospital stay, the patient was switched from intravenous steroids to Prednisone.
The respiratory pathogen panel came back positive for parainfluenza virus. During the hospital stay, the patient's clinical condition continued to improve, and she was discharged from the hospital.

The health plan's determination is upheld.

The inpatient stay was not medically necessary for this patient.
The review of the medical records demonstrated that the patient's respiratory symptoms were not suggestive of impending or actual respiratory arrest. There was no documentation of severe hypoxemia or hypercapnia. There was no mention that the patient had severe airflow obstruction, including significant abnormalities, including a significant decrease in peak expiratory flow rate. The imaging studies did not show any infiltrates, open pneumothorax, or pneumomediastinum. There was no evidence that the patient required respiratory treatments that could have only been performed at the acute inpatient level of care. Overall, the patient's hospitalization was relatively short and during this period of time respiratory symptoms significantly improved. She remained afebrile and did not even require supplemental oxygen.
Taking into consideration all these facts, the patient could have been appropriately managed at a lower level of care status.