Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma.
Treatment: Inpatient Hospital Admission.

The insurer denied the Inpatient Hospital Admission.  The denial is upheld.

The patient is a male child with medical history significant for reactive airway disease (RAD), allergic rhinitis, and atopic dermatitis that presented to the emergency department with one-hour history significant for shortness of breath and belly breathing. In addition, the patient had productive cough, clear rhinorrhea, congestion, decreased activity, post-tussive emesis, and subjective fever. Historically, triggers included dogs and seasonal allergens. The patient was treated routinely with inhaled budesonide and was given a treatment that morning. The patient had family history of asthma in his father. The patient had four prior admissions for reactive airway disease. The patient's vital signs included temperature 100.0, heart rate 165, and respiratory rate 40 with 94% (percent) saturation in room air. The patient's examination was significant for tired appearance, acute respiratory distress with increased work of breathing, suprasternal and intercostal retractions, nasal congestion, moist mucous membranes, biphasic bilateral wheezing with adequate air entry, and non-focal neurologic exam. The patient was given three DuoNeb treatments, dexamethasone, and ibuprofen, and then re-evaluated. He continued to have biphasic bilateral wheezing and increased work of breathing. The patient was given a dose of magnesium and three albuterol treatments. Respiratory viral panel was obtained. The patient was re-evaluated again almost 90 minutes later. He still had minor retractions and tachypnea. He was admitted to the pediatric floor because he had not improved sufficiently to go home. Admission orders included vitals every four hours, albuterol every two hours, ipratropium every six hours for four doses, prednisolone every twelve hours for five days, maintenance intravenous fluids, Pulmonology consultation, and asthma action plan. 

On hospital day two, the patient was in no respiratory distress, breathing easily with no retractions. Albuterol was weaned sequentially to every three hours and then to every four hours. 

Infectious Disease consultation had been obtained with recommendation to hold antibiotics. Viral panel was positive for enterovirus-rhinovirus. Lab studies also revealed thrombocytopenia (platelets 85 thousand [K]), so Hematology was consulted with recommendation to repeat the labs. Repeat platelet count was 279 thousand. The patient was diagnosed with moderate persistent asthma, continued budesonide, and started Singulair per Pulmonology. The patient was eating and drinking well, so intravenous fluids were discontinued. The patient was deemed stable for discharge to follow-up in Pulmonary Clinic.

The acute inpatient admission was not medically necessary.

This young child with significant history of atopy presented to the emergency department with viral respiratory infection symptoms and increased work of breathing. He was treated aggressively in the emergency department, but after three DuoNeb treatments, three albuterol treatments, and steroids, he continued to have difficulty with ongoing bronchospasm. While it was reasonable to monitor the patient in the hospital for resolution of bronchospasm and demonstration of adequate intake, he was overall hemodynamically stable with no oxygen requirement 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.