Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Difficulty Breathing. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is overturned. 

The patient with a history of asthma and otitis media who presented to the emergency department (ED) with increased work of breathing and a cough. She had seen her pediatrician twice in the preceding week and was prescribed antibiotics for otitis media, albuterol, and a course of prednisone, all completed. The day prior to presentation she was given Decadron and a nebulizer along with instructions on when to return. The vital signs included a temperature of 36.8 degrees Celsius, heart rate 130, respiratory rate 44, and 97% oxygen saturation on high-flow nasal cannula with fraction of inspired oxygen (FiO2) 0.45. The examination was significant for an ill appearance, dry mucous membranes, left tympanic membrane bulging and dull with fluid, right tympanic membrane erythematous, clear lungs, benign abdomen, and non-focal neurologic exam. Laboratory evaluation was remarkable for leukocytosis (white blood cell count (WBC) 13.6 thousand (K), left shift (neutrophils 65%), no significant metabolic derangements. A respiratory viral panel returned positive for both respiratory syncytial virus (RSV) and enterovirus/rhinovirus. She was started on high-flow oxygen because of desaturation on room air and was subsequently admitted to the pediatric floor for further management. Admission orders included continuing the home asthma medications, weaning the high-flow as tolerated, weaning the supplemental oxygen as tolerated, a normal saline bolus followed by maintenance IV fluids, and ceftriaxone for otitis media. She was given albuterol metered dose inhaler (MDI) every two hours, famotidine, and systemic steroids. She was able to slowly wean to room air, and the albuterol was spaced out to every four hours. She was doing well, eating and drinking, deemed stable for discharge home. 

At issue is the medical necessity of an inpatient stay. 

The requested inpatient admission was medically necessary. The patient could not have been safely managed at a lower level of care. She required assisted ventilation and significant supplemental oxygen in addition to all of her home asthma medications and frequent bronchodilator treatments to recover from status asthmaticus. 
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. 
In the emergency department (ED), 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, admission is necessary. 
This child with a history of asthma and allergies became ill with both RSV and enterovirus/rhinovirus. As a result, she suffered significant respiratory compromise to the point of status asthmaticus and need for high-flow nasal cannula. She was aggressively treated for the duration of her hospital stay, and it took great effort to resolve her asthma exacerbation. This level of care is most consistent with the acute inpatient level of care.