Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status Asthmaticus

Treatment: Inpatient Hospital Admission

The insurer denied coverage for inpatient hospital admission

The denial is overturned

The patient is an obese male with a history of asthma and one previous admission for asthma. He had been sick for three days with upper respiratory infection (URI) symptoms. He then developed difficulty breathing and coughing and received 8 albuterol nebulizer treatments at home. When his respiratory symptoms did not improve with treatment for asthma at home his mother brought him to the Emergency Room (ER) for further treatment. His sister was also sick and had been admitted to the hospital with asthma.  In the ER, he was noted to have an increased work of breathing with tachycardia, shortness of breath, retractions and coarse breath sounds. He was treated with duoneb and albuterol every 2 hours. He required oxygen supplementation with 4 liters of oxygen at 28 percent. He was then switched to continuous albuterol when his breathing rate deteriorated and he became more short of breath. His mother agreed to treatment with intravenous (IV) dexamethasone and magnesium sulfate. His venous blood gas was 7.42 with a partial pressure of carbon dioxide (PCO2) of 42 indicating significant respiratory distress. He was transferred to the Pediatric Intensive Care Unit (PICU) for intensive asthma therapy.  

The insurer has denied the admission as not medically necessary and indicated that there was no documentation in the medical record to support the need for inpatient treatment.

According to Sawicki and Haver, "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 Scarfone, "DISPOSITION - The decision regarding disposition (eg, discharge to home, continued observation, or hospitalization) is based upon both clinical and social factors. Discharge to home - Children who have marked improvement in clinical parameters within the first one to two hours of therapy may be discharged home. Marked improvement is manifested by diminished or absent wheezing and retracting and increased aeration that is sustained at least 60 minutes after the most recent albuterol dose. 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. This includes patients who continue to have significant wheezing and retracting, poor aeration, or altered mental status, such as drowsiness or agitation."

The patient was treated appropriately in the ER for status asthmaticus. He did require oxygen supplementation for ongoing hypoxemia. He had a history of previous asthma admission and had failed outpatient therapy for asthma exacerbation. His hypoxemia and respiratory distress with elevated venous pCO2 of 42 demonstrated that he was not stable enough to be discharged. The decision to admit him to the hospital for ongoing treatment was appropriate and consistent with the standard of care for status asthmaticus. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is reversed. Medical necessity is substantiated.