Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a medical history significant for asthma including one prior pediatric intensive care Unit (PICU) hospitalization who presented to the emergency department (ED) with a three-day history significant for a productive cough, nasal congestion, and wheezing unresponsive to bronchodilator treatment at home. Vital signs included a temperature of 37.1 degrees Celsius, heart rate 133-151, respiratory rate 30-35, and blood pressure 107/70. Examination was significant for tachypnea, accessory muscle usage, nasal flaring, generalized wheezing, and a non-focal neurologic exam. Laboratory evaluation revealed an elevated white blood cell count (WBC) count 16.8 thousand (K), left shift with 95% (percent) neutrophils, mild hypokalemia 3.2, hyperglycemia 151, and metabolic acidosis 17. Coronavirus (COVID) screen was negative. A chest x-ray was unremarkable. A venous blood gas included partial pressure of carbon dioxide (pCO2) of 37.4. He was treated with DuoNebs, dexamethasone, ibuprofen, and albuterol. Despite aggressive therapy, he remained tachypneic with abdominal breathing. He was given a dose of magnesium and admitted for ongoing management of status asthmaticus. Admission orders included continuous cardiopulmonary monitoring, regular diet for age, half maintenance intravenous (IV) fluids, albuterol every three hours, prednisone twice daily for five days, and pulmonology consultation. He did well overnight, with a good appetite, resolution of wheezing and respiratory distress, and no fevers. He was deemed stable for discharge home with diagnosis of mild persistent asthma and prescriptions for routine inhaled steroids, allergy follow-up, and albuterol as needed.
The inpatient stay 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. Asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough. 
Asthma is classified in terms of severity, with intermittent and persistent symptoms. Patients with mild persistent asthma experience symptoms up to two days per week with nighttime awakenings up to two times per month. These patients use bronchodilators for rescue two or less days per week, and may experience up to one exacerbation annually requiring systemic corticosteroids. Treatment proceeds in a stepwise fashion based on classification. Patients with mild intermittent asthma start with step 1, using short-acting bronchodilators as needed for symptoms. Patients with mild persistent asthma typically start at step 2 with daily low-dose inhaled corticosteroids, using short-acting bronchodilators as needed for symptoms. The most severe patients require step 6, using high-dose inhaled corticosteroids along with long-acting bronchodilators and oral systemic corticosteroids. This young boy with mild persistent asthma presented to the ED with persistent bronchospasm, increased work of breathing, and cough despite appropriate bronchodilator treatment at home. He was aggressively treated in the ED with DuoNebs, systemic corticosteroids, IV fluids, and magnesium, but remained sufficiently symptomatic that discharge home was not considered a safe option.
While it was reasonable and medically necessary to continue hospital-based therapy, he had no supplemental oxygen requirement, no evidence of impending respiratory failure, and no underlying chronic medical conditions to necessitate acute inpatient admission. He could have been safely managed at a lower level of care than inpatient.