Appeal type: Medical necessity
Decision: Overturned

This is a patient who presented with congestion, increased work of breathing, subjective fever and a cough one day prior to presentation. Her mother noticed a dry cough the day prior and on the morning of presentation, the child felt warm and developed a runny nose. The mother also stated she was having decreased by mouth (PO) intake. There were no sick contacts at home but the patient attends daycare. An exam in the emergency department (ED) documented belly breathing, no retractions and rhonchorous breath sounds in all lung fields. There was no wheezing. She was treated initially with saline nebulizers and suction as the ED physician felt her presentation was most compatible with bronchiolitis. She did not have any improvement, heart rate (HR) remained 152 and respiratory rate (RR) 52. Belly breathing was still observed as well as faint expiratory wheezing. Due to a family history of asthma and past medical history of eczema a trial of Duoneb and oral steroids was attempted. She was treated in the ED with 1 albuterol and 1 Duoneb treatment and oral prednisolone with some improvement. She persisted with tachypnea and belly breathing so she was admitted for further management with a diagnosis of first asthma exacerbation.
She was noted to have a temperature of 100.8 degrees Fahrenheit so she was treated with Motrin. The admission physical exam documented tachypnea with RR 48. The supervising attending provider documented RR 44 and mild subcostal retractions. She was started on Albuterol nebulizers every two hours (q2hrs) and remained overnight and was eventually spaced to q4hrs in the morning as well as continued oral steroids. Eventually, her symptoms improved except for intermittent coughing. The patient had one episode of post-tussive emesis while in house. She was cleared for discharge home with instructions to follow up with her primary medical doctor (PMD) in 1 week. She was also referred to asthma and allergy specialists. She was sent home with a prescription for an albuterol inhaler and spacer chamber.
The health plan's determination overturned. This patient presented with complaints of increased work of breathing and documented wheezing, tachypnea, belly breathing and retractions which was not resolved after reasonable ER management. She was given multiple nebulizer treatments but persisted with belly breathing, tachypnea and retractions. Her condition was such that the admitting physician placed her on frequent albuterol nebulizations every 2 hours. Such frequent nebulizations require close monitoring and frequent respiratory assessments. Given persistence of her symptoms despite adequate and acceptable ER management, inpatient stay was medically necessary for this patient.
Based on her failure of ED treatment with steroids and multiple nebulized beta agonists, inpatient hospital admission was medically necessary. She persisted with retractions and belly breathing as well as tachypnea. She was placed on albuterol every 2 hours. Such frequent nebulizer treatments would require more intense monitoring and would be considered appropriate for inpatient level of care. She needed continued close monitoring and care as well as asthma education given this was her first asthma exacerbation. For these reasons, an inpatient level of care was medically necessary.