Appeal type: Medical necessity
Decision: Overturned

Respiratory System
Inpatient Hospital

This is a patient with a past medical history significant for asthma, eczema, and environmental allergies who presented to the hospital with complaints of worsening shortness of breath that had been going on for one week. During the emergency room visit, the patient received treatment with bronchodilators, intravenous magnesium, and Prednisone. She was discharged from the emergency department but returned to the hospital on the same day.
She complained of a subjective fever and cough productive of brownish sputum. She also complained of wheezing. The review of systems was negative for chest pain, abdominal pain, nausea, vomiting, diarrhea. The patient complained of leg edema.
During her second emergency department visit, the patient received treatment with Duonebs and intravenous SoluMedrol. Her patient's peak flow was 150 liters per minute (l/min). It was indicated that the patient was tachycardic. A chest x-ray was performed and did not show any acute abnormalities.
When the patient was seen by the admitting physician, she was afebrile, heart rate was 103 beats per minute (bpm), respiratory rate 18, blood pressure 124/76, respiratory rate 18, and oxygen saturation 95% on room air. The patient was sitting in bed in no acute distress, was well-groomed, and she was able to speak in full sentences. She used the accessory muscles of respiration. The cardiac exam revealed tachycardia. The lung exam demonstrated diffuse expiratory wheezing with the use of accessory muscle of respiration. The rest of the physical exam was unremarkable.
A venous blood gas was obtained and appeared to be within normal limits. Her sodium was 139, potassium 3.2, chloride 107, bicarbonate 26, blood urea nitrogen (BUN) 9, creatinine 0.54, and glucose 91. The white blood cell count was 12.23, hemoglobin 13.4, hematocrit 40.2, and platelets 258.
A computed tomography (CT) angiogram of the chest was done and demonstrated bronchial thickening with no evidence of CT detectable pulmonary emboli.
The patient was admitted to the hospital with a diagnosis of acute asthma exacerbation. She received treatment with intravenous corticosteroids and bronchodilators.
In the hospital, the patient was seen by a pulmonologist two days after the presentation in the emergency department. By that time the patient's respiratory status significantly improved.
According to the pulmonologist, the patient had mild persistent asthma with an acute exacerbation. The pulmonologist recommended obtaining pulmonary function tests (PFTs) as an outpatient.
As a result of the treatment, her symptoms significantly improved and her oxygen saturation remained in the normal range. The patient was discharged from the hospital with a prescription for Prednisone taper and bronchodilators via nebulizers. At issue is the medical necessity of an inpatient stay.
The health plan's determination is overturned.

The inpatient stay was medically necessary for this patient because of the severity of her condition, that was defined by relapse of the symptoms after she received treatment in the emergency department on the day of admission, and also severely diminished peak expiratory flow pointing toward higher severity of acute asthma exacerbation.
According to the Merck Manual Professional version, hospitalization generally is required if patients have not returned to their baseline within 4 hours of aggressive emergency department treatment.
Criteria for hospitalization vary, but definite indications are
-	Failure to improve
-	Worsening fatigue
-	Relapse after repeated beta-2 agonist therapy
-	Significant decrease in partial pressure of oxygen (PaO2) (to less than [<] 50 millimeters of mercury [mm Hg])
-	Significant increase in PaCO2 (to greater than [>] 40 mm Hg)
In this clinical case, the patient relapsed after the treatment that she received during her first emergency department visit. It was indicated that during her first emergency department visit the patient received treatment with beta-2 agonists as well as corticosteroids, and still became short of breath again, and this prompted her second emergency department visit.
Per the MCG criteria, one of the criteria for inpatient admission is expiratory flow rate between 40% and 60% of predicted or personal best after treatment that included current or recent use of oral corticosteroids for asthma. In this clinical case, the patient received treatment with Prednisone that was administered during the first emergency department visit, and the patient's expiratory flow was registered at 150 L/min. Even though the patient's personal best peak expiratory flow was unknown, the calculation of the peak expiratory flow based on the patient's age, height, race, and sex should have been 430 L per minute with the lower limit of normal of 322 L per minute. Therefore, the patient's peak expiratory flow was at best in the range between 40 and 60% of predicted.
Taking into consideration all of this information, the patient required treatment at the acute inpatient level of care because of the severity of her condition, recurrence of her symptoms, and the need for frequent administration of breathing treatments, as well as close monitoring for signs of possible respiratory failure.