Diagnosis: Respiratory System-Asthma
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. The reviewer has overturned in whole the health plan's determination.

The patient has a past medical history of hypertension, hyperlipidemia, and asthma who was admitted with complaints of shortness of breath (SOB) associated with wheezing. Vital signs were remarkable for an oxygen saturation of 87%. Physical exam was notable for bilateral wheezing. Lab work was notable for partial pressure of carbon dioxide (pCO2) 60, peak flow was 250 with predicted 500 liters per minute, positive troponins. Imaging studies: transthoracic echocardiogram (TTE) showed no significant findings. An electrocardiogram (EKG) showed no acute ischemia. The patient was diagnosed with an asthma exacerbation and treated with pulmonary treatments, intravenous (IV) steroids, magnesium, and IV antibiotics. The patient was discharged in stable condition with discharge peak flow of 340.

The hospital stay was medically necessary at an acute inpatient level of care. This patient presented with a one-week history of worsening shortness of breath (SOB) associated with wheezing. The patient was evaluated and found to have bilateral wheezing. The patient was treated aggressively in the emergency department (ED) with DuoNeb's, IV antibiotics, and IV steroids. In addition, the patient's peak flow was 250, which was 50% of the patient's predicted. This is compounded by the patient's tachypnea, positive troponins, elevated pCO2 and hypoxia requiring 2 liters of oxygen therapy, which is a significant change from the patient's baseline. Overall, this patient suffered a severe exacerbation of asthma and could not have been safely treated at a lower level of care.