Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status Asthmaticus 
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

This is a child with a history of a left hydronephrosis and an illness with malaria when living in another country. The child had been sick with a viral illness for 3 days with a cough and fever. When the child developed increased work of breathing, the parents administered one dose of the brother's albuterol in the home. When the child's difficulty breathing persisted, the father brought the patient to the emergency room (ER) for treatment.

In the ER the patient was noted to have respiratory distress with diffuse biphasic wheezing, retractions, and decreased air entry. The patient was treated with 3 doses of Combivent, steroids, and magnesium sulfate. Because there was a history of a decrease in urine output, the patient was also given a bolus of intravenous (IV) normal saline. A chest x-ray was unremarkable. When the patient's wheezing and suprasternal and subcostal retractions did not improve with treatment in the ER, the decision was made to admit the child with a diagnosis of status asthmaticus for continued treatment with albuterol every 2 hours.

The patient was treated appropriately in the ER for a cough, wheezing, and respiratory distress. The patient was noted to be in acute respiratory distress with retractions and increased work of breathing upon arrival to the ER. There is a note in the medical record to indicate that the patient required an IV bolus of normal saline and IV magnesium sulfate for persistent wheezing. The patient was requiring albuterol every 2 hours and could not have been safely discharged to home. The admission to the hospital was medically necessary for status asthmaticus.

As noted in UpToDate (Richard J Scarfone, MD, FAAP. "Acute asthma exacerbations in children: Emergency department management." UpToDate.):

1) Disposition - The decision regarding disposition [e.g. ("for example"), discharge to home, continued observation, or hospitalization) is based upon both clinical and social factors. 2) 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. 3) Continued treatment and observation - Children with some, but incomplete improvement within the first two hours of therapy require continued observation. Incomplete response is manifested by modest, but insufficient benefits in degree of wheezing, retracting, and aeration. 4) During continued observation, patients with partial improvement should continue to receive albuterol nebulization's every 30 to 45 minutes (or continuously) for another one to two hours, after which a decision regarding hospitalization or discharge home is made. 5) 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.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for the inpatient emergency admission is substantiated.