Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma.
Treatment: Inpatient admission. 
The insurer denied: Inpatient admission. 
The denial is upheld.

The patient is a male child with medical history significant for moderate persistent asthma, his last hospitalization having been a year prior and one PICU (pediatric intensive care unit) admission. He presented to the ED (emergency department) with cough and fever. His family was administering albuterol every four hours overnight, but he continued to cough. With post-tussive spitting up. Pulse oximetry at home ranged 92-96%.

The patient's vital signs included temperature 97.6, heart rate 134, respiratory rate 24, saturating 94% in room air. His examination was significant for coughing, tearful presentation, mild intercostal interactions with mild respiratory distress, moist mucous membranes, bilateral faint expiratory wheezing, and non-focal neurologic exam. He was placed in observation upon initial evaluation. He was treated with one DuoNeb and dexamethasone. He was re-evaluated multiple times, at first with faint wheeze. He was given another dose of DuoNeb, with persistent suprasternal retractions and tachypnea. At the end of the observation period, he continued to have persistent retractions. He was given another DuoNeb and arrangements were made for admission for management of viral URI (upper respiratory infection) and asthma exacerbation. Admission orders included albuterol 2.5mg(milligram) every two hours and wean as tolerated, prednisolone every twelve hours, supplemental oxygen as needed for oxygen saturation less than 90%, asthma action plan, and pulmonologist follow-up. Viral panel returned positive for enterovirus/rhinovirus. He was able to wean quickly to albuterol every four hours. The next day his lungs were clear with good air entry, and he was deemed stable for discharge home.

The inpatient 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. Status asthmaticus is defined as "severe asthma that fails to respond to inhaled beta-agonists, oral or intravenous steroids, and requires admission to the hospital for treatment." (1) Unfortunately, asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough. "Despite advances in asthma management, acute exacerbations continue to be a major problem in patients our review findings support the importance of controlling persistent asthma early episodic intervention appeared to be crucial in preventing severe attacks and future exacerbations." (2)

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 male child with history of moderate persistent asthma presented to the ED (emergency department) with respiratory distress and cough refractory to bronchodilators at home. He was treated with back-to-back treatments and steroids and admitted for persistent symptoms. While it was reasonable and appropriate to monitor him in the hospital for improvement versus deterioration, he was overall hemodynamically stable with no evidence of progression to acute respiratory failure and no need for supplemental oxygen. He did not require acute inpatient admission and could have been safely managed at a lower level of care.

The inpatient 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. Status asthmaticus is defined as "severe asthma that fails to respond to inhaled beta-agonists, oral or intravenous steroids, and requires admission to the hospital for treatment." (1) Unfortunately, asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough. "Despite advances in asthma management, acute exacerbations continue to be a major problem in patients our review findings support the importance of controlling persistent asthma, early episodic intervention appeared to be crucial in preventing severe attacks and future exacerbations." (2)

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 male child with history of moderate persistent asthma presented to the ED (emergency department) with respiratory distress and cough refractory to bronchodilators at home. He was treated with back-to-back treatments and steroids and admitted for persistent symptoms. While it was reasonable and appropriate to monitor him in the hospital for improvement versus deterioration, he was overall hemodynamically stable with no evidence of progression to acute respiratory failure and no need for supplemental oxygen. He did not require acute inpatient admission and could have been safely managed at a lower level of care.