Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma; Respiratory syncytial virus (RSV)
Treatment: Inpatient hospital admission
The insurer denied coverage for Inpatient hospital admission.
The denial is overturned.

This is a female child patient with a history of asthma. The patient had been sick with a viral illness for 2 weeks and had been placed on oral antibiotics for 7 days by her pediatrician for an otitis media.  When her coughing persisted, the patient was given albuterol at home for 7 days.  When her breathing became labored, the patient's mother brought the patient to the Urgicare.  The patient was noted to be in acute respiratory distress and was treated with bronchodilator.  When her increased work of breathing did not improve, the patient was transferred to the Emergency Room (ER) for further treatment. In the ER, the patient was noted to be appearing tired with difficulty breathing.  The patient had increased work of breathing with tachypnea, increased work of breathing and retractions.  The patient was noted to have a decreased ability to tolerate oral liquids.  The patient was treated with a normal saline intravenous (IV) fluid bolus, antibiotics, steroids and 3 back-to-back treatments with combivent. The patient's test for respiratory syncytial virus (RSV) virus was positive and a lactate level was elevated at 5.2.  The patient's chest x-ray was normal.  The patient's electrocardiogram (EKG) performed for her persistent tachycardia showed ST segment depression.  A cardiology consult was requested and an echocardiogram was performed in the ER which ruled out myocarditis, but detected a patent ductus arteriosus (PDA).  When the patient's respiratory symptoms did not improve with treatment in the ER and her ability to tolerate oral feedings did not improve, the decision was made to admit the patient with a diagnosis of status asthmaticus for ongoing treatment with albuterol and IV fluids.
  
Based on the review of the medical record and literature, the patient was treated appropriately in the ER for a cough, wheezing and respiratory distress. The patient had been taking albuterol for 7 days at home and despite ER treatment, the patient continued to have ongoing respiratory distress with persistent wheezing and increased work of breathing.  The patient appeared tired and unable to tolerate oral liquids, and required intravenous (IV) fluids.  It was appropriate and consistent with the standard of care to admit the patient to the hospital for ongoing treatment with albuterol and IV fluids.  The patient had failed outpatient management of her asthma and there was also concern for possible sepsis because of lactic acidosis noted on her bloodwork. The patient also had persistent tachycardia and abnormal EKG that required cardiology workup for possible myocarditis. Although myocarditis was ruled out, this patient presented with multiple concerns that required inpatient level of care, treatment and monitoring. The patient continued to be in respiratory distress with a diagnosis of status asthmaticus and was not stable enough to be sent home.  Thus, inpatient level of care was medically necessary for this patient.

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

The carrier's denial of coverage for the inpatient hospital services should be overturned.  The medical necessity is substantiated.