Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Shortness of breath, rhinorrhea, congestion, and cough.
Treatment:  Inpatient admission.

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

The patient is a male child with medical history significant for asthma managed with albuterol as needed, as well as eczema and hypothyroidism. He presented to the ED (emergency department) with one-day history of shortness of breath, rhinorrhea, congestion, and cough. His symptoms worsened overnight, with some chest pain and headache. He was treated with three doses of albuterol approximately four hours apart with no sustained benefit.

The patient's vital signs included temperature 36.3, heart rate 104, respiratory rate 24, and blood pressure 116/58. His examination was significant for pausing for breath when talking (but able to count to ten in one breath), congestion and rhinorrhea, moist mucous membranes, regular heart rate and rhythm, intercostal and subcostal retractions, decrease breath sounds at both bases, expiratory wheezing, and non-focal neurologic exam. He was given three CombiVent treatments dosed every twenty minutes as well as a dose of prednisolone. On re-examination, he demonstrated belly breathing and tracheal tugging. He was started on albuterol every two hours and referred for admission.

The patient's admission orders included asthma pathway, albuterol every two hours, oral corticosteroids, Flovent twice daily, and regular diet. He was able to tolerate spacing his treatments to every four hours. He had no need for supplemental oxygen for the duration of his hospital stay. He was able to tolerate a regular diet, and he had no fevers. He was deemed stable for discharge to continue twice daily Flovent and five-day course of prednisolone.

No, 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 known history of asthma and atopic disease presented to the ED (emergency department) with URI (upper respiratory infection) symptoms and asthma exacerbation refractory to albuterol treatments given at home. He was treated aggressively in the ED (emergency department), but because of persistent evidence of increased work of breathing, he was admitted to the pediatric ward for further management. While it was reasonable and appropriate to monitor him in the hospital for response to treatment, he was overall hemodynamically stable with no evidence of impending respiratory failure, no supplemental oxygen requirement, and ability to drink sufficiently to prevent dehydration. He did not require acute inpatient admission. He could have been safely managed at a lower level of care, such as observation.