Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath and Wheezing
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is Upheld

The patient is a school aged male child with medical history significant for asthma. The patient was transported to the emergency department via EMS (emergency medical services) with five-day history of cough and wheeze unresponsive to home albuterol. On this day, he developed fever and increased work of breathing, prompting the trip to the ED (emergency department).
The patient's vital signs included temperature 38.7, heart rate 147, respiratory rate 26, and blood pressure 125/71. Examination was significant for tachypnea, increased work of breathing with retractions, bilateral diffuse wheezing, bilateral infrascapular crackles, and non-focal neurologic exam.
The patient was treated with two DuoNebs. Chest x-ray revealed bilateral perihilar infrahilar peribronchial thickening representing reactive airway disease or pneumonia. He was also treated with dexamethasone, and IV (intravenous) fluid bolus, ibuprofen, and magnesium. Laboratory evaluation was significant for venous blood gas with normal pH 7.39, hypokalemia with potassium 2.8, hyperglycemia with glucose 156, and negative rapid viral screen (Covid, influenza, RSV [respiratory syncytial virus]). His oxygen saturation decreased to the low 90s with persistent bronchospasm prompting decision to admit to the pediatric floor for albuterol every three hours. Admission orders included continuous cardiopulmonary monitoring, diet for age, IV (intravenous) fluids, albuterol every three hours, azithromycin daily, Tylenol as needed, methylprednisolone IV (intravenous) every twelve hours, and potassium parenteral bolus. The following morning, he was wearing nasal cannula oxygen, and was mildly tachypneic with bilateral expiratory wheezing left more than right and tachycardia. He had no retractions. New orders included repeat metabolic panel, continue parenteral steroids, continue IV (intravenous) fluids, continue albuterol every three hours, and continuous pulse oximetry. He was able to wean albuterol to every four hours and transitioned to enteral steroids. Potassium had normalized to 4.7. By the afternoon, he was deemed stable for discharge.

The Inpatient Hospital 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. There are many possible triggers including exposure to allergens and upper respiratory viral infections. 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.
This young school-aged child with history of asthma presented to the ED (emergency department) with cough, new-onset fever, and increased work of breathing. He was treated aggressively in the ED (emergency department), but after DuoNeb treatments, magnesium, and steroids, he developed an oxygen requirement and continued to have evidence of bronchospasm. While it was reasonable to monitor him in the hospital for resolution of bronchospasm and resolution of fever, he was overall hemodynamically stable with no further fevers and no evidence of impending respiratory failure. He did not require acute inpatient admission and could have been safely managed at a lower level of care.