Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Shortness of breath.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient, who was pregnant, presented to the hospital with complaints of shortness of breath and wheezing. She had cold-like symptoms for one week, which included a runny nose. Subsequently, she started to have a dry cough and shortness of breath without fever or chills. The patient denied nausea, vomiting, or diarrhea. Her previous pregnancy was uncomplicated, and this time she denied any vaginal bleeding. When seen by the admitting physician, she complained of some chest discomfort that started as a burning sensation in her throat and went down to the chest. This sensation was not associated with taking a deep breath.

In the emergency department, the patient received treatment with bronchodilators, an intravenous infusion of magnesium sulfate, and intravenous antibiotics. Blood cultures were obtained.

Vital signs were a temperature of 97.9 degrees Fahrenheit (F), blood pressure 115/71, pulse rate 114 beats per minute (bpm), respiratory rate 21 breaths/minute, and oxygen saturation 95% on room air.

When seen by the admitting physician, she was awake, alert, and oriented, well-nourished and in no respiratory distress. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits.

The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), carotid bruits. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The gastrointestinal (GI) exam was within normal limits. The rest of the physical exam was unremarkable.

Laboratory evaluation revealed a white blood cell count of 15.2, hemoglobin 12.4, hematocrit 35.3, and platelets 358. The sodium was 135, chloride 102, bicarbonate 17, blood urea nitrogen (BUN) 7, creatinine 0.53, and glucose 76. A chest x-ray was completed with pregnancy guard. It demonstrated left perihilar prominence of uncertain clinical significance.

The patient was admitted to the hospital with a diagnosis of shortness of breath. The patient was screened for coronavirus disease 2019 (COVID-19). She was started on antibiotics empirically for possible pneumonia. Obstetrics/gynecology (OB/GYN) service was consulted. The patient was ruled out for COVID-19 and influenza. Her procalcitonin was negative. The patient was also ruled out for a deep vein thrombosis (DVT) since her lower extremity dopplers did not show evidence of deep vein thrombosis. The patient was seen by a pulmonologist, who diagnosed the patient with acute bronchitis that was most likely viral in nature.

While in the hospital, the patient's white blood cell count was trending down. Since the patient's clinical condition continued to improve, she was discharged home with oral Zithromax, Budesonide. The patient was recommended to follow up with her OB/GYN as an outpatient.

At issue is the medical necessity of an inpatient stay.

The review of the medical records demonstrated that the patient most likely had acute bronchitis and not pneumonia. Acute bronchitis is usually a self-limited condition. The majority of acute bronchitis cases are caused by viruses. Even though the patient was suspected to have pneumonia, there was no strong evidence that she required admission at the acute inpatient level of care. She had no significant hypoxemia, hemodynamic instability, severe or persistent altered mental status, dehydration, bacteremia. There was no evidence that the patient failed outpatient treatment or had respiratory findings such as dyspnea that did not respond to outpatient or observation care treatment. There were no indications that the patient had complicated pleural effusions such as empyema. This patient was not immunocompromised. The pregnancy was uncomplicated.

This coincides with the Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 24th Edition Criteria for Pneumonia. A review of the criteria demonstrated that neither the severity of the patient's condition nor the complexity of the services provided justified admission at the acute inpatient level of care.

Overall, she remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. The care could have been provided at a lower level.