Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma Exacerbation
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is overturned.


This patient with a past medical history significant for asthma, hypertension, pulmonary tuberculosis with fibrosis, and a history of a pulmonary abscess that required decortication and RIPE [rifampin, isoniazid, pyrazinamide, and ethambutol] therapy presented with complaints of shortness of breath that had been going on for one week. Reportedly, the patient utilized bronchodilators in inhalers and nebulizers, as well as steroids. She stated that despite treatment there was no improvement in her condition. The patient stated that in the last several months before the admission she had multiple episodes of shortness of breath and wheezing. Reportedly, these symptoms were previously evaluated by her family doctor.
The patient stated that she lived on the fourth floor and at baseline, she was able to walk up three flights of stairs before needing to rest. Lately, she was able to walk up only several steps without getting short of breath.
When seen by the admitting physician the review of systems was positive for wheezing, shortness of breath,and dyspnea on exertion. She denied a cough, fever, recent travel, or sick contacts.
At the time of the initial evaluation, the patient was afebrile, her heart rate was 98 beats per minute (bpm), respiratory rate 21, blood pressure 159/73, and oxygen saturation 95% on room air. The patient appeared to be an obese female who was in no acute distress. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), carotid bruits. She had bilateral crackles and mild wheezing. The cardiac exam revealed a regular heart rate and rhythm, without murmurs, rubs, or gallops. The abdominal exam was unremarkable. The rest of the physical exam was within normal limits.
Laboratory evaluation revealed that the white blood cell count was 12.3, hemoglobin 12.2, hematocrit 38.5, and platelets 311. The sodium was 140, potassium 4.4, bicarbonate 23, blood urea nitrogen (BUN) 14, creatinine 0.7, and glucose 125.
A computed tomography (CT) scan of the chest revealed opacification in the right middle lobe compatible with atelectasis of pneumonia. The patient was admitted to the clinical decision unit (CDU) with an acute asthma exacerbation. She was started on bronchodilators and intravenous SoluMedrol, and a pulmonary consultation was obtained.
According to the pulmonologist, the patient had an asthma exacerbation that failed outpatient therapy. The pulmonologist recommended continuation of treatment with Duoneb every 4 hours, continuation of treatment with intravenous corticosteroids, and the addition of hypertonic saline to the breathing treatments. As a result of the treatment, the patient's clinical condition improved. Her shortness of breath completely resolved. The patient's vital signs remained within normal limits and there were no crackles or wheezing on physical exam. Therefore, the patient was discharged from the hospital in stable clinical condition. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was medically necessary in this clinical case. It was clearly documented that the patient tried outpatient treatment of the acute asthma exacerbation and still remained highly symptomatic. She had a decreased tolerance for physical activity compared to the baseline. Even after she received treatment in the emergency department and at the CDU, her peak expiratory flow was only around 65% of predicted values. The patient required frequent treatments with bronchodilators via nebulizer, administration of hypertonic saline by a respiratory therapy, treatment with intravenous corticosteroids.
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:
-Failure to improve
-Worsening fatigue-Relapse after repeated beta-2 agonist therapy
-Significant decrease in partial pressure of oxygen (PaO2) (to less than [<] 50 millimeters of mercury [mmHg])
-Significant increase in partial pressure of carbon dioxide [PaCO2] (to greater than [>] 40 mmHg)
In this clinical situation, the patient had already received treatment adequate for her condition before the admission, and still remained highly symptomatic.
Therefore, the she was appropriately admitted to the hospital and was started on intravenous corticosteroids every 12 hours as well as bronchodilators administered every 4 hours. Also, the pulmonologist recommended supplemental oxygen therapy as well as an addition of hypertonic saline to help to break up her secretions. All of these measures significantly added to the complexity of care provided in the hospital. Even though the patient was afebrile and hemodynamically stable, she had a very slowly resolving acute asthma exacerbation that failed appropriate outpatient treatment, therefore admission at the acute inpatient level of care was medically necessary. The most effective way to provide all necessary treatment was admission at the acute inpatient level of care.