Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is overturned.

The patient has a history of asthma and presented to the primary medical doctor (PMD) on the day of admission for a fever and fast breathing. He received albuterol in the office and was sent to the emergency room (ER) by Emergency Medical Services (EMS) for non-resolving tachypnea. En route to the hospital, he received another albuterol nebulizer. Additionally, his mother reports that 2 days prior, he had cough. His mother provided 6 puffs of albuterol with no help and called EMS who provided one dose of Decadron and 2 albuterol nebulizers with improvement. Since the day prior, he had been having decreased by mouth (PO) intake, drinking only fluids and passing urine well. 
In the ER he presented febrile with a temperature of 104 degrees Fahrenheit, heart rate (HR) 176, respiratory rate (RR)in the 60s. He was described as ill appearing and in respiratory distress with suprasternal and intercostal retractions, coarse breath sounds throughout and no wheezing. His oxygen saturation was 97% on room air. He arrived with an albuterol nebulizer in progress. No wheezing was noted. He received one Duoneb times (x) 3 and in view of his continued tachypnea he was placed on high flow nasal cannula (HFNC) 20 liters (L) 30% oxygen (O2) with improvement. Flu and respiratory syncytial virus (RSV) were negative. A chest x-ray (CXR) was also read as negative. A basic metabolic panel (BMP) revealed hyponatremia with sodium (Na) 131. He was given acetaminophen and ibuprofen for fever and also received 2 normal saline (NS) boluses. The assessment was moderate respiratory distress, likely viral bronchiolitis.
He was admitted for acute respiratory failure and dehydration secondary to adenovirus and rhinovirus bronchiolitis. He had HFNC for managing his distress as the physician mentioned he was unable to speak. He was admitted to the Pediatric Intensive Care Unit (PICU) for further management. The admission exam described the patient to be well appearing with a RR of 32, no retractions, positive (+) transmitted sounds on HFNC. He was started on Albuterol as needed (PRN). His respiratory viral panel returned positive for rhinovirus and adenovirus. In the PICU, he was initially on HFNC 20L 30%, NPO, on maintenance intravenous fluids (IVF) and Albuterol PRN. Overnight he was weaned from HFNC to 2L NC. He was febrile with a maximum temperature (Tmax) 102.3. He was advanced to room air and PO feeds. Repeat chemistry showed a normalized Na to 137. He was comfortable on room air and was considered stable for transfer to the floor. Overnight, the patient remained stable on room air and did not require any further albuterol throughout his hospital course. PO intake improved with a reassuring urinary output. By hospital day (HD) #3, he was deemed stable for discharge with Albuterol PRN and instructions to follow up with the PMD in 1-2 days.
At issue is whether the inpatient stay is medically necessary.

The inpatient stay is medically necessary. He presented with marked respiratory distress. He was treated with Duoneb x 3 in the ER. Despite adequate ER management he continued with distress and had to be placed on high flow nasal cannula for additional respiratory support. Patients on HFNC cannot be cared for at a lower level of care. HFNC requires frequent respiratory assessments which would need to be managed at inpatient level of care. He was placed NPO due to the respiratory support being provided and on a cardiopulmonary monitor in the ICU. PICU nurses documented, on more than one occasion during his stay, mild subcostal retractions, once while on HFNC and twice after HFNC was discontinued. He failed outpatient management as he continued to worsen despite frequent Albuterol treatments and Decadron. This patient required inpatient level of care to adequately care for his condition.