Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System-Asthma
Treatment: Inpatient Hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

The patient has a past medical history significant for persistent asthma who came to the emergency department with complaints of being unable to breathe while he was playing video games. The patient came to the hospital the day before this presentation with complaints of shortness of breath. At that time, he received treatment with bronchodilators, Prednisone, and Zithromax. On the day of admission, the patient called 911 since he had experienced minimal improvement with the treatment with bronchodilators. At the time of initial evaluation, the patient denied fever and cough. He complained of chest pressure. He reported smoking marijuana twice a day.

Upon initial evaluation in the emergency department, the patient's temperature was 97.5F (degrees Fahrenheit), heart rate 139 beats per minute (bpm), respiratory rate 32 breaths/min, blood pressure 131/40, and oxygen saturation 90-100% (per cent). The patient appeared to be a well-developed, well-nourished individual. He was tachycardic but had a regular heart rhythm with no murmurs. The patient was able to speak only in short sentences. There was bilateral inspiratory and expiratory wheezing. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. The rest of the physical exam was unremarkable.

The patient was admitted to the hospital with an asthma exacerbation, tachycardia, pneumomediastinum, and a small left apical pneumothorax seen on the chest x-ray. The patient was admitted to the telemetry floor and continued to receive Solu-Medrol, Zithromax, bronchodilators, and supplemental oxygen. Daily peak volumes were ordered.  The patient was seen by a cardiothoracic surgeon who recommended no intervention. A daily chest x-ray was recommended to monitor the resolution of pneumothorax. The patient was also seen by a pulmonologist for evaluation of acute asthma exacerbation that was complicated by pneumothorax and pneumomediastinum with subcutaneous emphysema. The pulmonologist recommended utilizing a nonrebreather mask with 100% oxygen for 24 hours to help resolve pneumomediastinum and DuoNeb (Ipratropium-albuterol) treatments every 4 hours around-the-clock. Due to persistent pneumomediastinum and pneumothorax, cough suppression with dextromethorphan was also ordered. In addition, treatment with broad-spectrum antibiotics for community-acquired pneumonia as well as intravenous Solu-Medrol twice daily was ordered. As a result of the treatment provided in the hospital, the patient's clinical condition significantly improved. Serial chest x-ray showed resolution of pneumothorax and unchanged emphysema/pneumomediastinum. The patient was counseled on marijuana cessation. Since the patient's clinical condition continued to improve, he was transitioned to outpatient care.

The admission at the acute inpatient level of care was justified in this patient who presented with pneumothorax, and pneumomediastinum, with a respiratory rate over 30 breaths/min, and severe tachycardia.
Even though the patient's hospital stay was relatively short, the clinical condition was very serious when the patient presented with his asthma exacerbation that was associated with very serious complications including pneumothorax and pneumomediastinum. This patient required very close monitoring for signs of clinical deterioration, and treatment with a high concentration of supplemental oxygen, bronchodilators, antibiotics, and intravenous corticosteroids.
Considering the severity of the patient's condition and the complexity of services provided,  the care could not have been provided at a lower level. This coincides with nationally accepted standards of care.