Appeal type: Medical necessity
Decision: Overturned

This is a patient with a past medical history of asthma who presented with an asthma exacerbation for the past few days. She was only on Albuterol as needed (PRN) at home. She presented with complaints of a runny nose for 2 days. She had difficulty breathing for a 1 day. Her mother was giving albuterol and saline nebulizers every 2-3 hours at home. She received 5 nebulizer treatments throughout the day. She continued to have difficulty breathing noted as belly breathing and retractions with home treatments so she was brought to the emergency room (ER). She did have some post-tussive emesis at home. She was tolerating by mouth (PO) well with normal urine output. There were no known sick contacts. She had no fever.  She was described as in moderate distress with tachypnea, retractions/abdominal respirations and course breath sounds. The ER physician documented that the patient was very sleepy/lethargic on arrival. She was given 3 back to back nebulizers and intravenous (IV) steroids. She did show some improvement but was still symptomatic so an IV Magnesium bolus was administered as well as an IVF bolus. A complete blood count (CBC) and basic metabolic panel (BMP) were normal, respiratory syncytial virus (RSV) /Influenza polymerase chain reaction (PCR) were negative. A chest x-ray (CXR)was done and was consistent with reactive airway disease (RAD), no signs of atelectasis or pneumonia. The last ER assessment reports patient still with retractions 2 hours post last nebulizer treatment. The decision to admit the patient was made at that time and she was placed on every (Q) 2 hour albuterol nebulizer treatments. She was continued on steroids and albuterol was eventually weaned to Q4hrs. The patient tolerated the weaning well and was cleared for discharge home. She was discharged with instructions to continue Albuterol Q4 hours and complete a 5 day course of steroids. She was instructed to follow up (F/U) with her primary medical doctor (PMD) in 1 day.
The health plan's determination is overturned.
This patient presented with respiratory distress evidenced by tachypnea, lethargy and retractions. Although the patient improved and appeared to respond to ER management, she still had tachypnea and retractions at the time of admission that the admitting physician felt the need to order Albuterol treatments every 2 hours. Treatments every two hours along with frequent vital sign monitoring would constitute an inpatient admission. This child, upon presentation, was in severe enough respiratory distress to require IV magnesium. Those patients require closer monitoring as they are at risk for relapse and deterioration. Her condition would warrant a higher level of care therefore inpatient level of care was medically necessary.
The literature recommends admission and close monitoring for patients with persistent respiratory distress in the face of an asthma exacerbation after proper ER management has been implemented. Systemic steroids and bronchodilators were not sufficient to control her symptoms. These patients are more likely to experience deterioration and need for higher acuity of care once admitted. She still had tachypnea and retractions at the time of admission and required nebulizer treatments every two hours. Such frequent treatments which would also require increased monitoring would not be appropriate for a lower level of care. Of note, this patient also failed outpatient management as her mother reported giving 5 nebulizer treatments prior to arrival to the ED lethargic and in moderate to severe respiratory distress.