Appeal type: Medical necessity
Decision: Upheld

Respiratory System
Inpatient Hospital

Diagnosis: Shortness of Breath
Treatment: Inpatient Hospital Stay. The insurer denied the Inpatient Hospital Stay. 
The denial was upheld.

This is a patient with a past medical history significant for childhood asthma, anxiety, hemophilia, tobacco abuse, and polysubstance abuse who presented to the emergency department with complaints of shortness of breath. According to the history and physical (H&P) note, the patient had been feeling short of breath for one month. Apparently, his shortness of breath worsened one day before the day of admission, and this prompted the patient to come to the emergency department, where he was placed on bi-level positive airway pressure (BiPAP). His condition improved and he was discharged home. Reportedly, the patient still remained dyspneic and complained of wheezing. Because of these symptoms, the patient decided to come back to the emergency department.
The patient was awake, alert, and oriented to person, place, and time. His head, eyes, ears, neck, throat (HEENT) exam was unremarkable. The cardiovascular exam revealed normal heart sounds. The pulmonary exam demonstrated normal effort. The patient was in no acute distress. He had rales throughout. The rest of the physical exam was unremarkable.
Laboratory evaluation revealed that the white blood cell count was 23.2, hemoglobin 16.5, hematocrit 51.5, and platelets 255. Sodium was 132, potassium 4.0, chloride 97, bicarbonate (HCO3) 23, blood urea nitrogen (BUN) 21, and glucose 133. The patient's troponin was normal.
A chest x-ray revealed no focal infiltrates. The patient was admitted to the hospital with a diagnosis of an upper respiratory infection with an asthma exacerbation. The patient was started on bronchodilators, received SoluMedrol, Azithromycin. Other admitting diagnoses included polysubstance abuse and anxiety.
On the next day after the date of admission, the patient was suspected to have stridor. Considering his history of hemophilia, the patient was ordered a chest x-ray to rule out hematoma as a reason for possible stridor. The chest x-ray showed a nodular infiltrate in the right upper lung. A computed tomography (CT) scan of the neck was also performed and showed no evidence of upper airway obstruction. It demonstrated a right upper lobe infiltrate, suspicious for pneumonia.
As a result of the treatment, the patient's clinical condition significantly improved and the patient was discharged home. To continue the treatment of pneumonia, the patient was switched to Doxycycline. The switch to Doxycycline occurred because the patient was noted to have a prolonged Q-T interval. At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of inpatient stay was not medically necessary for this patient because of the relatively mild symptoms and overall low acuity. The review of the medical records demonstrated that the patient unlikely had an acute asthma exacerbation at the time of admission to the hospital.
Based on a review of the physical exam, even though the patient complained of shortness of breath, he was in no respiratory distress. The respiratory rate was 19 and oxygen saturation 98% on room air. The peak flow was documented as 549 liters per minute (l/min). There was no wheezing mentioned on the exam.
At the same time, the patient had an elevated white blood cell count and rales on the lung exam, which were pointing toward possible pneumonia that was subsequently diagnosed based on the imaging studies.
According to the daily progress notes, it was noted that the patient was initially thought to have an acute asthma exacerbation. A subsequent workup revealed that the patient had pneumonia. Even though it was suspected that the patient could have stridor, this condition was mild and did not require treatment with supplemental oxygen. The CURB-65 Score for Pneumonia Severity estimates mortality of community-acquired pneumonia to help determine inpatient versus outpatient treatment.
In this clinical case, the patient received only one point, for the BUN being greater than 19 milligrams per deciliter (mg/dl). Based on the calculations, this patient belonged to a low-risk group for 30-day mortality; where outpatient treatment should be considered.
Taking into consideration all of this information, the patient did not fulfill the criteria for admission at the acute inpatient level of care.
The diagnosis was not completely clear at the time of admission. Subsequently, the patient complained of symptoms resembling stridor. Therefore, observation to ensure the stability of respiratory status, as well as to determine the correct diagnosis, was indicated and could have been performed at a lower level of care than inpatient.