Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Asthma exacerbation, congestive heart failure and questionable pneumonia 
 
Treatment:  Inpatient hospital services 

The insurer denied coverage for inpatient hospital services.  The denial is upheld. 

This patient is a female who presented to the Emergency Department (ED) with complaints of shortness of breath, wheezing and a productive cough with clear sputum of two weeks duration.  The patient's shortness of breath was at rest, as well as with exertion.  Her past medical history included asthma, diabetes mellitus, hypertension, congestive heart failure and allergic rhinitis.  The patient denied fever or sick contacts.  Vital signs at presentation included a temperature of 97.8F, a heart rate of 107, a respiratory rate of 20, blood pressure of 182/94 and oxygen saturations of 95% on room air.  A lung exam revealed a bilateral wheeze.  Cerebrovascular system (CVS) heart sounds S1 S2 were normal.  Bilateral lower extremity pitting edema was noted.  A peak expiratory flow (PEF) was 170/190.  

The white blood cell (WBC) count was 9.5 K, the hematocrit was 42, electrolytes were within normal limits, blood urea nitrogen (BUN) / Creatinine levels were normal and a Troponin was 0.01.  An EKG showed normal sinus rhythm and left ventricular hypertrophy.  A chest x-ray showed bilateral small effusions with a questionable infiltrate.  

The patient was admitted for treatment of an asthma exacerbation, congestive heart failure and questionable pneumonia.  The patient was treated with Lasix, steroids, nebulizers, Singulair, insulin sliding scale and ceftriaxone/azithromycin.  The patient was given three nebulizer treatments, magnesium and prednisone.  On a specified date the respiratory therapist notes described the patient's lung sounds as clear.  A peak expiratory flow (PEF) was 180/200 and her wheezing improved.  As per the History & Physical, the patient was speaking in full sentences.  Some coarse expiratory wheezing was noted.  The patient was in no acute distress.  A brain natriuretic peptide (BNP) level was 612.  A chest x-ray showed no focal infiltrates.  

This patient did not need acute inpatient hospitalization.  She could have been placed in observation status for up to 48 hours.  The patient could have been treated with diuretics, bronchodilators, steroids and antibiotics as needed.  The patient improved with treatment.  There was no definite evidence of pneumonia.  The patient was afebrile and the WBC count was normal.  Oxygen saturations were 95% on room air at presentation.  The patient was ambulatory.  She was tolerating oral intake.  The patient was treated with oral steroids and bronchodilators via nebulizers.  Pneumonia, even if suspected, was mild with a CURB 65 score of 0.  There was no evidence of myocardial infarction.  The patient was stable for discharge on oral medications after a period in observation while diagnostic testing and treatment were initiated.  The patient had responded to treatment in the Emergency Department.  She was afebrile, hemodynamically stable, and not hypoxic.  The WBC count was normal with some increase noted after treatment with steroids which was likely a steroid effect.  The prior denial is upheld.  

The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

The carrier's denial of coverage for the inpatient hospital services is upheld.  The medical necessity is not substantiated.