Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute asthma exacerbation
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a boy with a history of asthma. He presented to the Emergency Department for an emergency evaluation due to chest tightness and shortness of breath.  According to his mother, he was having vomiting and chest tightness for one day prior to initial evaluation.  He had one known sick exposure, his brother, who had similar symptoms at home.  He was having worsening chest pain and poor oral intake prompting his mother to bring him to the hospital for further evaluation.

The patient initially presented to the Emergency Department with blood pressure of 103/67 mmHg (millimeters of mercury), heart rate of 131/minute, respiratory rate of 22/minute, temperature of 99.6 Fahrenheit, SaO2 (pulse oximetry) of 97%, and general appearance of discomfort.  Due to concern for acute asthma exacerbation in the setting of viral illness and further deterioration of the patient's condition, the patient was immediately seen by ED (emergency department) staff and the attending Emergency Physician.

On initial evaluation, the patient complained of chest pain, cough, congestion, runny nose and nausea.  He appeared tachypneic and uncomfortable with prolonged expiration and decreased air movement.

The patient was initially treated with DuoNeb breathing treatments, Decadron and IV (intravenous) fluids with minimal improvement.  He had an episode of emesis with persistent tachypnea.  He was given IV (intravenous) magnesium with no improvement.  Due his persistent symptoms in the setting of known asthma, the decision was made to admit for further monitoring with continued breathing treatments.

The treating physician was concerned for respiratory distress and inability to tolerate oral intake.  The physician's plan for the patient consisted of intravenous fluids, bronchodilators, intravenous steroids and continuous monitoring of his respiratory status.  The patient initially improved with albuterol nebulization and was able to be spaced every four hours.  Patient caregivers were provided with further teaching concerning the use of an inhaler with spacer during this admission.  There was also concern for potential child abuse based on comments that the patient had made to staff.  Social work was consulted and the safety evaluation was performed, with the patient's caregiver ultimately being cleared.  He was discharged to home in improved condition.

Authorization for the admission was denied by the health plan, which claimed that the patient did not meet criteria per InterQual Acute Pediatric Asthma.  These criteria were described as including continued symptoms after 1-3 hours in the ED (emergency department) with 3 or more doses of medication, unresolved wheezing with cyanosis, a change in mental status, or have a chronic health condition with an abnormal heart rate, increased work of breathing with an oxygen level below 96% or decreased amount of the air leaving the lungs of 26-69%, and being on 5 or more medications, have 2 or more hospitalizations within the year or dependent on a machine to breathe.

The treating institution claimed that the admission was justified due to concern for acute respiratory distress and oral intolerance of solids and liquids secondary to his respiratory complaints requiring prompt therapy.  The patient had known reactive airway disease with treatment with albuterol, with the acute episode presumed likely to a viral infection. This resulted in increased work of breathing, decreased air movement, tachypnea and bronchoconstriction and chest tightness.  He was refractory to treatment with bronchodilators, steroids and magnesium in the ED (emergency department), making admission for prolonged therapy necessary.

Yes, the Inpatient admission was medically necessary.
There are several indicators listed in the medical record that support admission of this young boy for acute asthma.  He had persistent wheezing and chest discomfort, his respiratory rate was as high as 35/minute, he had a metabolic acidosis and elevated lactate and he was refractory to standard treatment for at least 3 hours.  In addition, the possibility of child abuse arose, making it possible that he did not have appropriate caregivers at home.

The criteria listed by the health plan are not appropriate for routine admission of children with asthma exacerbations or status asthmatics.  Rather, they look more like criteria for ICU (intensive care unit) admission.  He did meet usual criteria for admission for asthma as indicated in many sources, such as reference 1, below.