Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System - Shortness of breath. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a male with hypertension, polysubstance abuse (ecstasy, cocaine, alcohol, tobacco), and asthma who was sent to the emergency room (ER) for detoxification and complaints of shortness of breath, chest tightness and difficulty breathing. He had presented to another hospital the day before with similar symptoms. Last cocaine and ecstasy was the day prior to presentation. Physical exam documented by the ER physician noted wheezing and rhonchi. Peak expiratory flow was 280 liters per minute (L/min.). Electrocardiogram (EKG) showed sinus rhythm [HR (heart rate) 98] and a corrected QT interval (QTc) of 492. Vital signs documented the temperature at 36.7 degrees Celsius, heart rate (HR) 104, respiratory rate (RR) 18, blood pressure (BP) 171/113, with oxygen saturation of 97% on room air. Labs were notable for a urine toxicology screen positive for cocaine, venous blood gas (VBG) 7.35 | 48| 55, otherwise labs were unremarkable. Chest x-ray was unremarkable. The patient was given albuterol / levalbuterol, antihypertensives (oral), methylprednisolone, and famotidine in the ER. The patient was admitted with concern that his QTc interval was prolonged. He received duo-nebs and prednisone. He was monitored for withdrawal from alcohol and other substances. QTc returned to normal limits. Electrolytes remained within normal limits. The patient was discharged. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The inpatient stay is not medically necessary for this patient. Services could have been rendered appropriately at a lower level of care status. The patient presented to the ER with symptoms of shortness of breath and dyspnea with exertion with vitals that were within normal limits, with no need for supplemental oxygen, and a VBG with appropriate potential hydrogen (pH), elevated carbon dioxide (CO2) in the setting of a RR within normal limits not indicating patient was going to tire out. The patient was documented to be wheezing and have expiratory rhonchi. Peak expiratory flow documented at 280 L/min. Predicted is 431 L/min - 570 L/min (Hankinson et al.). Unclear what his baseline peak expiratory flow rate (PEFR) was. Given the patient has a history of substance abuse (cocaine, tobacco), peak expiratory flow would be predicted to be lower. Even if the patient's baseline peak expiratory flow rate was at the maximum (570 L/min), his current peak expiratory flow rate was 50% of possible peak which would be classified as moderate obstruction, but again his personal best flow rate is unknown (Choi et al.). He received treatment in the ER but continued to have symptoms despite not having vital sign changes or evidence of respiratory distress indicating a need to admit the patient for monitoring and symptom management (Wollard et al.). Cocaine is likely to cause the patient's symptoms in the setting of presumed underlying lung disease from chronic use of adulterant substances and tobacco (Tseng et al.). QTc prolongation is common in patients who utilize cocaine and patients who utilize cocaine have a higher risk of arrhythmias (Taylor et al.).
Based on this information, the patient would be expected to have symptom relief within 24-48 hours of admission and decline in QTc to within normal limits with elimination of cocaine (Wollard et al., Tseng et al., Taylor et al.). Therefore, patient would not be expected to stay longer than 48 hours or less than 2 midnights. The patient could have been safely treated at a lower level of care status.