Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System 
Treatment: Inpatient Hospital 

The insurer denied the inpatient stay. The denial is upheld in whole. 

The patient is a generally healthy male who presented to the hospital with complaints of cough and fever for two weeks. These symptoms were associated with worsening shortness of breath. Especially, the patient complained of dyspnea on exertion. The patient denied any previous history of asthma or chronic obstructive pulmonary disease (COPD). 

In the emergency department, the patient received treatment with oral corticosteroid as well as bronchodilators via nebulizer. When the patient was seen by the admitting physician, he appeared awake, alert, in no acute distress. At that time, he was afebrile, the respiratory rate was 20, blood pressure was 121/79, and pulse rate was 79 beats per minute (bpm), with an oxygen saturation of 100% on room air. 

The patient appeared to be a well-developed, well-nourished individual who was not in acute distress. He had a normal head, eyes, ears, nose, throat (HEENT) exam. Lungs were clear to auscultation. The cardiovascular exam was unremarkable. The abdominal exam was benign. The rest of the physical exam was unremarkable. Laboratory evaluation revealed a white blood cell count of 7.1, hemoglobin 14.7, hematocrit 44.1, platelets 284. Sodium was 137, potassium 4.3, chloride 102, bicarbonate 23, blood urea nitrogen (BUN) 19, creatinine 1.16, and glucose 94. 

A chest x-ray demonstrated small opacity in the left lung base. The radiologist suggested that this could represent atelectasis. There was no focal pulmonary consolidation. The patient was admitted to the hospital with a diagnosis of shortness of breath and cough. The etiology of these symptoms was unclear. The admitting physician suggested to rule out reactive airway disease versus infection. The admitting physician stated that the rapid influenza test was negative, and the patient had no leukocytosis and was afebrile. 

At the time of admission, the patient was started on treatment with bronchodilators, Prednisone. The patient's symptoms significantly improved within the first 24 hours.
It was indicated in the discharge summary that at the time of discharge the patient had no shortness of breath or dyspnea on exertion. He regained his baseline functional status. Therefore, the patient was discharged home on the very next day after the day of admission. 

The health plan's determination is upheld, in whole. 

The inpatient stay was not medically necessary. The review of the medical records demonstrated that in this clinical case the patient presented with acute bronchitis. For most patients with acute bronchitis, symptoms are self-limited, resolving in about one to three weeks. Reassurance and symptom control are the cornerstones of care. Antibiotics are not recommended for routine use. 

By definition, acute bronchitis occurs in the absence of chronic obstructive pulmonary disease (COPD). The majority of cases of acute bronchitis are caused by infection with respiratory viruses, such as rhinoviruses, coronaviruses, influenza viruses, and respiratory syncytial virus. Bacteria are rare causes, accounting for less than (<) 10% of cases. 

For most patients, diagnosis can be made based on history and physical examination, and additional testing is not needed. Treatment should focus on patient education and supportive care. In this particular case, the patient had a normal temperature, respiratory rate, and oxygen saturation. The lungs were clear to auscultation, and there was no evidence of respiratory distress. The chest x-ray did not demonstrate definitive infiltrates or any other significant abnormalities that would prompt further evaluation or treatment. 

The patient's hospitalization was very short, and during the hospitalization, the patient remained afebrile and hemodynamically stable. There was no evidence of acute respiratory failure associated with his respiratory symptoms, there was no need for invasive or non-invasive mechanical ventilation. His respiratory symptoms were not associated with altered mental status. There was no evidence that the patient had any arrhythmias of immediate concern. Overall, he remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. 

Taking into consideration all these facts, neither the severity of the patient's condition nor the complexity of services provided rose to the acute inpatient level of care. The patient could have been safely managed at a lower level of care status.