Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned

The patient is an adult male who has a history of asthma and hypertension. The patient's hospital stay was approved only at an "Observation" level, but not at an "Inpatient" level. According to correspondence from the Provider, the patient is an adult male with a past medical history of asthma and hypertension who presented to the Emergency Room with a cough productive of whitish sputum, wheezing and shortness of breath of three days duration that was not relieved with albuterol at home. He stated that the symptoms were typical of his usual asthma exacerbation. He reported that he had also just completed a ten-day tapering course of prednisone prescribed by his Primary Care Physician with no improvement. The patient's presenting vital signs were significant for hypertension, tachycardia and hypoxia. Blood pressure was 177/105, heart rate was 110 beats per minute, respiratory rate was 20 breaths per minutes, and temperature was 97.6 Fahrenheit, with an oxygen saturation of 94% (percent). The patient's presenting physical examination revealed an increased work of breathing and wheezing. His initial laboratory testing revealed an elevated glucose level of 186 milligrams per deciliter (mg/dL). The pro-brain natriuretic peptide (BNP) was elevated at 182 picograms per milliliter (pg/mL). COVID-19 (coronavirus disease 2019) testing was negative. The chest x-ray showed increased opacities at the lung apices and increased lucency of the left lung, both present previously. A computed tomography angiogram of the chest was performed to assess for pulmonary embolism with none identified. There was mild bilateral bronchial wall thickening suggestive of bronchitis.

In the emergency room, the patient was placed on a cardiac monitor and on continuous pulse oximetry. He received solumedrol 125 milligrams intravenous piggyback (IVPB) once, ipratropium-albuterol (Duonebs) every 20 minutes for three doses and magnesium sulfate two grams intravenous piggyback once to treat the acute exacerbation of asthma. 

The proposed inpatient hospital admission was medically necessary.

The patient had a history of asthma and had failed both outpatient treatment and in-hospital observation treatment for status asthmaticus before being admitted as an inpatient for several days for further treatment and monitoring.

In the Observation Unit, the patient supplemental oxygen via nasal cannula or aerosol mask, Solu-Medrol 40 milligrams intravenous piggyback every eight hours and ipratropium-albuterol every four hours to treat the acute exacerbation of asthma. He received azithromycin 500 milligrams by mouth to treat the likely concomitant bronchitis. He received Norvasc five milligrams by mouth daily for hypertension, which represented an increased dose compared to his usual 2.5 milligram daily dose. He received Lovenox 40 milligrams subcutaneously daily for deep vein thrombosis prophylaxis. The patient reported minimal improvement of his symptoms with Duonebs. The decision was made to admit him to the inpatient unit as he had failed this trial of management in the Observation Unit. When seen by the admitting Attending Physician, the patient had persistent diffuse inspiratory and expiratory wheezing. On the inpatient unit, the patient received oxygen at two to three liters per minute via nasal cannula. He received solumedrol 40 milligrams intravenous piggyback every eight hours and ipratropium-albuterol via nebulizer every four hours to treat the asthma exacerbation. He received Symbicort two puffs two times daily as a controller medication. He received azithromycin 250 milligrams by mouth daily to treat the concomitant bronchitis. Montelukast ten milligrams by mouth nightly was added on Day #4. By the day of discharge, the patient's symptoms had subsided, and he was able to be weaned off supplemental oxygen. His oxygen saturation improved to 97%. He was deemed to be stable for discharge.