Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma.
Treatment: Inpatient Admission.
The insurer denied the inpatient admission.
The health plan's determination is upheld.

The patient is a female with a past medical history significant for asthma who presented to the emergency department with complaints of cough and chills. Her symptoms started the day before her presentation. The patient described a cough productive of yellowish sputum and also noticed worsening shortness of breath despite using her nebulizer at home. The patient denied previous asthma exacerbations that required intubation or mechanical ventilation. The patient endorsed marijuana use the night before her admission.

The review of systems was negative for nausea, vomiting, abdominal pain, and calf pain. Upon the initial evaluation in the emergency department, the patient underwent a chest x-ray that revealed a prominent right hilum with right mid to lower lung hazy opacity concerning for pneumonia with hilar lymphadenopathy.
Upon the physical examination, the patient was afebrile. Her pulse rate was 88 beats per minute (bpm), respiratory rate 20 breaths per minute, blood pressure 136/79, and her oxygen saturation was 93 percent (%) on room air. The patient was in no acute distress. The head, eyes, ears, neck, throat (HEENT) examination was within normal limits. The patient's neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), and carotid bruits. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. There was occasional wheezing and crepitus over the lower lungs. The rest of the physical examination was unremarkable.

The laboratory evaluation revealed that her white blood cell count was 6.6, hemoglobin 13.3, hematocrit 38.3, and her platelets were 200. Her sodium was 138, potassium 3.8, chloride 104, bicarbonate 26, blood urea nitrogen (BUN) 13, creatinine 0.7, glucose 83, calcium 8.9, phosphorus 2.9 and her magnesium was 1.7. The liver function tests were within normal limits. The patient tested negative for Coronavirus (COVID-19) and respiratory syncytial virus (RSV). The serology for influenza A was positive.
The patient was admitted to the hospital with dyspnea due to acute asthma exacerbation, pneumonia, influenza A, tobacco use, and an abnormal chest x-ray. The patient was seen by a pulmonologist who recommended continuous monitoring of oxygen saturation, treatment with bronchodilators, and a short course of systemic steroids as well as treatment with Tamiflu. It was also recommended to initiate treatment for community-acquired pneumonia due to abnormalities seen on the chest x-ray. During the hospital stay, the patient's clinical condition significantly improved and the patient was discharged home the day after the day of admission.

The requested health service/treatment of an inpatient admission was not medically necessary for the patient. There was no information that the patient had recurrent measurements of peak expiratory flow to see if it was significantly lower than the baseline. The patient's asthma exacerbation was relatively mild and did not require ventilatory assistance. There was no evidence of significant hypoxemia, carbon dioxide (CO2) retention, or persistent dyspnea following a period of observation. There were no signs of hemodynamic instability, altered mental status, or radiographic evidence of complications such as tension pneumothorax requiring inpatient treatment. The patient's symptoms improved within a short period of time, and the hospital stay was brief. Based on these factors, an alternate level of care would be the most appropriate course of action.

This coincides with Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care 26th Edition criteria for Asthma. The patient did not fulfill the criteria to qualify for the hospital stay under the acute inpatient level of care. An alternate level of care would have been appropriate for the patient.