Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Breathing Problems
Treatment:  Inpatient Hospital
This is a patient with a past medical history significant for asthma, hypothyroidism, as well as benign prostatic hyperplasia (BPH), who presented to the emergency department with a one-day history of shortness of breath.  Prior to this admission the patient had recently been admitted for an acute asthma exacerbation, and at that time he had similar symptoms.  He was discharged home with a prescription for Prednisone taper and antibiotics.  The patient stated that he had never been intubated because of the asthma exacerbation.
At the time of this admission, he denied fever, chills, nausea, vomiting, abdominal pain, dizziness, chest pain, cough, recent travel, or sick contacts.  In the emergency department, the patient was given treatment with nebulizers and Azithromycin with improvement.
The review of systems was obtained on admission and was negative for fever or chills but positive for shortness of breath and wheezing.  The rest of the review of systems was negative.
The patient was resting comfortably in bed in no acute distress.  He had inspiratory and expiratory wheezing in all lung fields.  The rest of the physical exam was unremarkable.  Laboratory evaluation revealed that the white blood cell count was 14.8, hemoglobin 13.6, hematocrit 44.2,and  platelets 213.  Sodium was 140, potassium 3.8, chloride 103, bicarbonate 20, blood urea nitrogen (BUN) 20, creatinine 1.13, and glucose 151.  Venous blood gas demonstrated that the patient's potential of hydrogen (pH) was 7.38, which was normal.
A chest x-ray was unremarkable without pleural effusions, pulmonary consolidation, pulmonary edema, or pneumothorax.
A computed tomography (CT) scan of the chest was performed and demonstrated dilated esophagus with air-fluid level suggestive for aspiration of severe gastroesophageal reflux disease (GERD).  Gastroenterology (GI) follow-up was scheduled as an outpatient.
The patient was admitted to the hospital with a diagnosis of acute asthma exacerbation and started on intravenous corticosteroids, bronchodilators.  It was indicated in the history and physical exam note that on the day of admission patient's peak flow was 170 milliliters (mL).
As a result of the treatment, the patient's clinical condition improved, and the patient was discharged from the hospital.  The health plan's determination is upheld.

The inpatient services were not medically necessary.
Based on the Merck Manual Professional Version article related to acute asthma exacerbation, 
"Hospitalization generally is required if patients have not returned to their baseline within 4 hours of aggressive emergency department treatment.  Criteria for hospitalization vary, but definite indications are: 1) Failure to improve, 2) Worsening fatigue, 3) 	Relapse after repeated beta-2 agonist therapy, 4) Significant decrease in partial pressure of oxygen (PaO2) (to less than [<] 50 millimeters of mercury (mmHg), 5)  Significant increase in partial pressure of carbon dioxide (PaCO2) (to > 40 mm Hg)."

In this clinical case, it was unclear if the patient returned to the baseline after receiving treatment in the ER.  At the same time, there was no evidence that the patient failed to improve after the initial treatment that was provided in the emergency department. There was no evidence that the patient relapsed after repeated beta 2 agonist therapy.  In this case, it was elected to obtain venous blood gas at the time of the initial evaluation.  Therefore, the last 2 circumstances related to PaO2 and PCO2 could not be assessed fully since in the book there was a reference to the arterial blood gas and not the venous blood gas.  The PaO2 is usually lower in the venous blood gas and a PaCO2 is usually higher in the venous blood gas compared to the arterial blood gas.  However, the patient's PaO2 was 72 in the venous blood gas, which was in the acceptable range and the PaCO2 was only mildly elevated at 42, which was in the lower range of normal.  Taking into consideration these facts, it is clear that the patient did not have significant hypoxemia or hypercarbia.  The patient's peak flow on the day of admission was greater than 50% of the known baseline.  Taking into consideration all of this information, care could have been provided at a lower level than inpatient to reassess the respiratory status as well as response to treatment.  The severity of the asthma exacerbation did not justify admission at the acute inpatient level of care.  In addition to the criteria noted above, the patient's chest x-ray did not show any significant abnormalities and his tachycardia improved.
According to the progress note, the patient was afebrile and hemodynamically stable.  He was walking around without any distress.  His peak flow improved up to 200 milliliters (mL).  He had decreased air entry with diffuse wheezing and rhonchi but no crackles.  Laboratory evaluation demonstrated a leukocytosis, but this was explained by the use of corticosteroids.
Overall, the patient's respiratory status significantly improved within a short period of time.  It was unclear if this patient who had a history of asthma ever had a normal respiratory exam without wheezes.
The severity of the patient's acute asthma exacerbation did not support admission at the acute inpatient level of care, since the patient responded to treatment provided in the emergency department, sustained steady improvement, had unremarkable venous blood gas, unremarkable chest x-ray, and no other medical conditions that would justify admission at the acute inpatient level of care.