Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Respiratory System - Cough
Treatment:  Inpatient Hospital

This is the case of a male with past medical history of severe asthma/chronic obstructive pulmonary disease (COPD) with chronic methylprednisolone dependence and history of intubation previously, coronary artery disease with stenting x4, rheumatoid arthritis, cerebrovascular accident, hypertension, hyperlipidemia, obesity, and gout, who presented to the emergency room (ER) with shortness of breath, cough with blood tinged sputum, wheezing, and chest pain associated with coughing.

On presentation, he was afebrile with blood pressure 128/92, heart rate 82, respiratory rate 18, saturating 97% on room air (RA).  Exam noted wheezing with rhonchi and clinical concern for pneumonia.  Labs noted white blood cell (WBC) count 9.06, Hemoglobin (HGB) 12.5, platelets (PLT) 241, sodium (NA) 136, potassium (K) 4, blood urea nitrogen (BUN) 22, creatinine (Cr) 1, international normalized ratio (INR) 1.07, creatine kinase (CK) elevated at 656, troponin normal, and arterial blood gas with pH 7.41/partial pressure of carbon dioxide (pCO2) 33/partial pressure of oxygen (pO2) 85 on room air.  Influenza was negative.  Chest x-ray demonstrated no clear evidence of cardiopulmonary disease.  Electrocardiogram (EKG) showed no acute ischemia or arrhythmia.  In the ER, the patient was given NEBS, solumedrol and Magnesium.  The patient was given solumedrol, nebulizers, and magnesium intravenous (IV) in the emergency department.  He was subsequently brought into the hospital with concern for chronic obstructive pulmonary disease and asthma exacerbation and pneumonia.  Pulmonary subsequently saw the patient with assessment that he had wheezing with asthma and COPD exacerbation and possible right lower lobe pneumonia with plans for nebulizers, steroids, antibiotics, and theophylline with noted overall guarded prognosis.  The patient was treated with ongoing antibiotics, nebulizers, and aggressive IV steroids were needed given this patient had ongoing symptoms of asthma and COPD exacerbation with persistent wheezing.  Steroids were notably started at 40 milligrams (mg) IV every (q) 6 hrs., ultimately able to be tapered to q 8 hrs. and then tapered to q 12 hours.  It was not until that his wheezing finally improved to the point that pulmonary felt that he could be safely changed from IV solumedrol to oral prednisone and discharged with ultimate diagnosis of asthma and COPD exacerbation and pneumonia.
The issue in question is whether care at the inpatient level of care was medically necessary.

The health plan's determination is overturned.
Yes, the requested health service of inpatient stay was medically necessary for this patient.  As previously noted, this patient with severe steroid-dependent asthma/chronic obstructive pulmonary disease presenting with clear evidence of exacerbation with productive sputum, shortness of breath and persistent wheezing despite high dose steroids every 6 hours in the setting of clinical concern for pneumonia required medically necessary inpatient care given high dose steroids needed for ongoing wheezing and coughing lasting beyond a reasonable period of observation.
It is additionally noted that Milliman Care Guidelines (MCG), used nationally to evaluate medical necessity for level of care, note that inpatient admission is warranted for "severe underlying COPD with new or worsened signs or symptoms of COPD (dyspnea, tachypnea, cough, sputum production)" or for "high risk acute comorbidity (e.g. pneumonia) with new or worsened signs or symptoms of COPD (dyspnea, tachypnea, cough, sputum production)."  This patient with clear severe COPD with steroid dependence at baseline with symptoms of COPD exacerbation and with clinical concern for pneumonia met both of these criteria.  Inpatient stay was medically necessary.