Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath; wheezing
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. The service under review is Inpatient Hospital Admission. This service was denied and this decision is being appealed.

The patient's medical history includes asthma, prior hospitalizations (not in several years). His presenting symptoms included runny nose, heavy breathing, fever, cough, shortness of breath, and wheezing. In the ER (emergency room) he had respiratory rate 24, SpO2 (pulse oximetry) 91-94% room air. His exam was significant for intercostal and subcostal retractions and wheeze. He tested positive for rhino/enterovirus. His chest x-ray was clear. His blood tests including CBC (complete blood count), basic metabolic panel, and blood gas were unremarkable other than mild elevation of WBC (white blood count) and CRP (C-reactive protein). In the ER (emergency room), he was given nebulized ipratropium-albuterol, intravenous dexamethasone, intravenous magnesium sulfate. The patient continued to have wheeze, and his SpO2 (pulse oximetry) was 93%, so the decision was made to admit.

No, the Inpatient admission was not medically necessary.
SpO2 (pulse oximetry) of 93% is generally considered to be just mildly low. Experienced physicians would generally not provide supplemental oxygen until it was lower. While the target goals vary between different hospitals and physicians, SpO2 (pulse oximetry) in the range of 88% to 92% would be considered to be acceptable for short term illnesses such as asthma exacerbations. Even in cases where supplemental oxygen is provided, observation level of care can be appropriate if the patient needs supplemental oxygen for just a single night.

According to reference 1: "For children in an ED [emergency department], indications for hospitalization and ICU [intensive care unit] consultation can vary considerably. In general, children that should be admitted include those with ongoing need for supplemental oxygen; severe acute asthma exacerbations despite 12 hours of continuous nebulization salbutamol (potential ICU [intensive care unit] admission); continued moderate acute asthma exacerbations for more than 46 hours after corticosteroid administration; continued deterioration on conventional treatments; social environment limiting the delivery of care; and risk factors for fatal asthma with a child living at a major geographic distance from appropriate care." The patient does not meet any of these criteria for inpatient stay.

Another publication [reference 2] touts the usefulness of using a standardized Respiratory Scoring Tool to determine necessity of inpatient stay, where a respiratory score 9 after 1 hour of treatment is felt to be sufficient to warrant hospitalization. Using this tool, the patient would have a score of 3 out of 12, not meeting admission criteria.

In conclusion, the patient was not sufficiently ill nor given adequate time in observation care to warrant inpatient level of care.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
The health plan did not deny the specific treatments that were provided, just the level of care under which it was done. The same treatments could have been provided under observation level of care.