Appeal type: Medical necessity
Decision: Overturned

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


This is a female child with a medical history significant for attention deficit hyperactivity disorder (ADHD), adjustment disorder, oppositional defiance disorder, and moderate persistent asthma that was taken to the emergency department (ED) via Emergency Medical Services (EMS) with the acute onset shortness of breath, rapid breathing, and hypoxia while at school. She had a three-day history of a runny nose, harsh productive cough, and subjective fevers. Her mother was treating her with albuterol every four hours without improvement. She had run out of her Montelukast and Singulair. Pulse oximetry was 89 percent (%.) She was initially taken to Urgent Care where the oxygen saturation was 90% (after two doses of DuoNeb). EMS was contacted and she was taken to the ED.
 The examination was significant for no acute distress, moist mucous membranes, wheezing and tachypnea, a benign abdomen, and non-focal neurologic exam. She was treated with DuoNebs and reassessed. Although improved, she continued to wheeze and she remained tachypneic, worsening with exertion. A chest x-ray was obtained, revealing a left-sided infiltrate. She was given additional DuoNeb treatments.  She was diagnosed with an acute asthma exacerbation secondary to pneumonia and referred for admission to the pediatric unit.
Admission orders included maintenance IV fluids, incentive spirometer as able, albuterol every two hours, Atrovent every six hours for four doses, Solumedrol IV, ceftriaxone every twelve hours, and azithromycin. Overnight, she was stable and able to tolerate a diet. The intravenous (IV) fluids were decreased to 50% and then weaned. Albuterol was spaced to every three hours in the morning. She was transitioned to prednisone and cefdinir (to replace the ceftriaxone), and continued azithromycin. By hospital day three, she was sleeping well with no acute events overnight and 98% saturation in room air. Subjective symptoms had improved significantly. She was deemed stable for discharge to follow-up with her pediatrician in one to two days, complete courses of the two antibiotics, and continue the prednisone for two more days.

The requested acute inpatient admission was medically necessary for this female patient with moderate persistent asthma. The patient failed outpatient treatment at home and aggressive treatment in the emergency department (ED), with persistent of symptoms. She could not have been safely and appropriately managed at lower level of care.
Pneumonia occurs because of inflammation of lung tissue from either infectious or non-infectious causes. Infectious causes include bacteria, viruses, and fungi. Non-infectious causes include aspiration, hypersensitivity reactions, and drug- or radiation-induced pneumonitis. Streptococcal pneumoniae is the most common bacterial pathogen of infants and young children, while Mycoplasma pneumoniae and Chlamydophila pneumoniae are the most common bacterial pathogens of children and adolescents. Other bacterial agents include Streptococcus pyogenes and Staphylococcus aureus. Viral pathogens include respiratory syncytial virus (RSV) and influenza, as well as rhinovirus, human metapneumovirus, parainfluenza, and adenovirus. Bacterial pneumonia typically occurs when organisms from the respiratory tract colonize the trachea and then gain access to the lungs, although hematogenous spread is also possible. Different bacterial pathogens invade according to their own specific pathogenic processes. Viral pneumonia occurs from viral spread along the airways accompanied by direct injury to the tissues with subsequent airway obstruction. Clinically, pneumonia is typically preceded by upper respiratory tract infection symptoms, including cough and runny nose. The type and degree of symptoms of lower respiratory tract infection depend upon the organisms and stage of illness.
Tachypnea, fever, cough, and chest pain may all be present. Physical examination findings may include decreased breath sounds, crackles, tachypnea, and shortness of breath. Infiltrate on chest x-ray is supportive of the diagnosis and may be accompanied by effusion. There may be laboratory indicators of infection, including leukocytosis and elevated inflammatory markers. Treatment is based on the suspected cause. Hospitalization may be warranted in the very young, patients with concurrent serious chronic medical conditions, moderate to severe respiratory distress, need for supplemental oxygen, dehydration, inadequate response to outpatient therapy, and complications such as empyema, abscess, or sepsis.
This female child with moderate persistent asthma was ill with a viral infection for several days before developing respiratory difficulty and acute asthma exacerbation. She had run out of two of her maintenance medications and did not respond sufficiently to albuterol every four hours at home. She was treated with multiple DuoNebs as well as parenteral steroids in the ED with persistent symptoms. X-ray revealed left-sided pneumonia. She failed outpatient treatment with persistent distress, she failed aggressive ED treatment with persistent wheezing and distress, and she had developed pneumonia as a complication. She required an inpatient level of care and could not have been safely managed at a lower level of care.