202307-165893
2023
Healthfirst, Inc.
Medicaid
Respiratory System
Inpatient Hospital
Medical necessity
Upheld
Case Summary
Diagnosis: Dyspnea, cough, chest pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.
The patient is a female with a history of asthma, breast cancer on chemotherapy, and hypertension. Her presenting complaints were dyspnea present for one month, a cough, and chest pain. The physical exam was notable for wheezing. Lab results were notable for venous blood gas (VBG) potential hydrogen (pH) 7.36, partial pressure of carbon dioxide (pCO2) 52.8, and white blood cell count (WBC) 18. Radiology was notable for a chest x-ray without evidence of pneumonia. The patient was admitted to an inpatient level of care for treatment of an asthma exacerbation. At issue is the medical necessity of an inpatient hospital stay.
The inpatient hospital admission is not medically necessary.
The patient presented with dyspnea and cough present for one month with signs and symptoms consistent with a mild asthma exacerbation evidenced by mild hypercapnia (some element of which is likely chronic) and wheezing. The patient did not have respiratory distress, severe symptoms, or hypoxia. A lower level of care would have been reasonable to monitor the patient for progression of symptoms and response to treatment.