Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma Attack and Pneumonia. 
Treatment: Inpatient Admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male. The service under review is Inpatient admission. This service was denied coverage by the health plan as not medically necessary, and this decision is being appealed. The patient's medical history includes asthma. 

The patient's initial symptoms were fever, cough, and runny nose. He had previous presented to his pediatrician and was an unspecified antibiotic for otitis media (only 2 doses were given). He presented to ER (emergency room) two days later, due to increased cough, headache, and abdominal pain, diagnosed with viral illness and discharged. He returned to the ER (emergency room) later than day due to vomiting that "looked like red blood." 

In the ER (emergency room), the patient's vital signs were as follows: Temperature 101.8F, HR (heart rate) 174, Respiration rate 24, SpO2 (pulse oximetry) was 92%. His exam was significant for no acute distress, not toxic appearing, mucus membranes being moist, heart with normal rate, good pulses, respiratory effort normal and without retractions, lung with wheezing and rales. Chest x-ray did not show pneumonia, just "findings suggestive of a viral process versus reactive airways disease." 

After treatment, the patient's lung exam was unchanged, and SpO2 (pulse oximetry) was 92-94%. He was admitted and treated with nebulized albuterol every two hours, daily IV (intravenous) ceftriaxone, oral prednisolone, and IV (intravenous) fluids (for decreased oral intake). 

No, the Inpatient admission was not medically necessary. 

The services that were provided to this patient did not require inpatient admission. The services could have been safely provided at an observation level of care. 

"For children in an ED [emergency department], indications for hospitalization and ICU [intensive care unit] consultation can vary considerably. In general, children that should be admitted include those with ongoing need for supplemental oxygen; severe acute asthma exacerbations despite 12 hours of continuous nebulization salbutamol (potential ICU [intensive care unit] admission); continued moderate acute asthma exacerbations for more than 46 hours after corticosteroid administration; continued deterioration on conventional treatments; social environment limiting the delivery of care; and risk factors for fatal asthma with a child living  at a major geographic distance from appropriate care." (1)  The patient did not meet any of these criteria for inpatient stay. 

Another publication (2) touts the usefulness of using a standardized Respiratory Scoring Tool to determine necessity of inpatient stay, where a respiratory score 9 after 1 hour of treatment is felt to be sufficient to warrant hospitalization.  Using this tool, the patient would have had a score of 2-3 out of 12, not meeting admission criteria. 

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient. 

The services that were provided to this patient did not require inpatient admission. They could have also been safely provided at an observation level of care.