Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever, Increased work of breathing.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male child with medical history significant for eczema and reactive airway disease/asthma. He presented to the ED (emergency department) with two-day history of fever to 102, nasal congestion, and cough, and same day history of increased work of breathing unresponsive to nebulized albuterol.

The patient's vital signs included temperature 37.1, heart rate 133, and respiratory rate 30 with 97% saturation in room air. Examination was significant for nasal congestion, mild respiratory distress with accessory muscle use including intercostal retractions, diffuse wheezing, and non-focal neurologic exam. Rapid screening for influenza A and B as well as RSV (respiratory syncytial virus) was negative.

The patient was treated with albuterol and ibuprofen followed by three DuoNebs and prednisolone. Chest x-ray was obtained revealing no infiltrates. He remained symptomatic so was admitted for ongoing management. Admission orders included albuterol every two hours, regular diet for age, and prednisolone twice daily. He had no further fevers and was eating and drinking well. However, he continued to have diffuse wheezing albeit with no accessory muscle use.

Pulmonology was consulted, adding Pulmicort to the patient's treatment regimen. He was able to tolerate spacing the albuterol treatments to every three hours and then to every four hours. He was deemed stable for discharge to follow-up with his pediatrician in one to two days. Prescriptions for Pulmicort, albuterol, and prednisolone were sent to the pharmacy.

No, the Inpatient admission was not medically necessary.
Asthma is an inflammatory process characterized by airway obstruction due to airway hyper-responsiveness, bronchospasm, airway inflammation, and mucus production. Gas exchange abnormalities are due to ventilation/perfusion mismatch, as a result of atelectasis and airway over-distention. Unfortunately, asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough.

In the ED (emergency department), primary management strategies include correction of hypoxia, rapid improvement of airflow obstruction, and prevention of progression. This is achieved with supplemental oxygen, bronchodilators, and steroids. Fluid hydration may also be necessary. For patients with moderate to severe exacerbations that do not respond to such intensive therapy in the ED (emergency department), admission is necessary.

In this case, this young male child with history of atopy presented with cold symptoms and wheezing unresponsive to bronchodilator treatments at home. In the ED (emergency department), he received additional bronchodilator treatments as well as systemic corticosteroids. He had no oxygen requirement and no signs or symptoms of dehydration. He remained symptomatic with persistent wheezing so was admitted for ongoing care. While it was not unreasonable to continue providing frequent bronchodilator treatments in the hospital setting, the child was overall hemodynamically stable with no need for supplemental oxygen, no indication of impending respiratory distress, good oral intake with no signs or symptoms of dehydration, and no significant underlying medical illness. He did not require acute inpatient admission and could have been safely and appropriately managed at a lower level of care.