Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia and status asthmaticus

Treatment: inpatient admission

The insurer denied coverage for inpatient admission. The denial was reversed.

The patient is a female child with a history of asthma and a previous hospitalization for asthma and pneumonia several years ago. She was coughing with a viral illness and was treated with albuterol and a dose of prednisone by her mother with no improvement in her symptoms. She began to have wheezing and shortness of breath, and her mother brought her to her clinic physician for treatment. In the clinic, she received three treatments with inhaled bronchodilators. When her wheezing and dyspnea did not improve, the decision was made to have her transported to the Emergency Room (ER) by Emergency Medical Services (EMS).

In the ER, she was noted to be in moderate respiratory distress. She was treated with DuoNeb with some improvement, but when her wheezing recurred, she was started on continuous albuterol nebulization. On physical examination, she was noted to have retractions and coarse crepitus over the right lung and bilateral wheezing. A chest x-ray was obtained which demonstrated right upper lobe pneumonia. She was treated with prednisone, an antibiotic, and magnesium. She also received two bolus treatments of intravenous (IV) normal saline. When her chest examination did not improve with treatment in the ER, the decision was made to admit her to the hospital with a diagnosis of pneumonia and status asthmaticus. The plan was to continue treatment with antibiotics, prednisone and continuous albuterol.

According to UpToDate: Acute asthma exacerbations in children: Inpatient management: "GENERAL APPROACH - Most children who require admission for asthma are initially treated in the emergency department (ED), although some are admitted directly from clinicians' offices. Thus, inpatient treatment is typically a continuation of therapies and monitoring that were started in the ED. Patients usually have received several albuterol treatments, often combined with ipratropium (children with an asthma exacerbation experience a lower risk of admission to the hospital if they are treated with the combination of inhaled short-acting beta agonists [SABAs] plus anticholinergic versus SABA alone, systemic glucocorticoids, and supplemental oxygen, when necessary, before arrival to the inpatient unit)"

According to UpToDate: Acute asthma exacerbations in children: Emergency department management: "DISPOSITION - The decision regarding disposition (e.g., discharge to home, continued observation, or hospitalization) is based upon both clinical and social factors.
Hospitalization - Patients who were moderately to severely ill on arrival and who have little improvement after initial therapy with beta agonists and systemic glucocorticoids require hospitalization."

The patient was treated appropriately in the ER for wheezing and shortness of breath from asthma and pneumonia. Her symptoms did not resolve with continuous albuterol and magnesium sulfate. The decision to admit her to the hospital was consistent with the standard of care for the patient's age with status asthmaticus and pneumonia

The insurer has denied this admission and stated that there was no documentation in the medical record to establish the need for admission to the hospital.

Based on the above, the medical necessity for the inpatient hospital services is substantiated.  The insurer's denial is reversed.