Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status Asthmaticus.

Treatment: Inpatient hospital stay.

The insurer denied coverage for inpatient hospital stay.  The denial is overturned.

This is the case of a male with a history of moderate persistent asthma who has four previous ER (emergency room) visits. The last visit was one month prior to this admission. He had been sick with allergy symptoms and nasal congestion for two days. His mother had been treating with oral allergy medication. He was then noted to have persistent coughing and increased respiratory effort. The mother did not have any albuterol at home and called emergency medical services (EMS) so that he could be taken to the ER for treatment. The EMS (emergency medical services) team administered one dose of Combivent during the transport to the ER.

In the ER, he was noted to be in significant respiratory distress with rapid breathing, subcostal and intercostals retractions. He had increased work of breathing with abdominal retractions. He was tachypneic, and on physical exam he had bilateral wheezing with decreased air entry and prolonged expiration. He was treated with 3 inhalations of Combivent, magnesium sulfate, and prednisone. He also was administered a bolus of normal saline by intravenous (IV). His wheezing and increased work of breathing did not improve. The decision was made to admit the child to the hospital with a diagnosis of status asthmaticus for continued treatment with albuterol every 2 hours.

According to UPTODATE article Acute asthma exacerbations in children: Inpatient management:

"GENERAL APPROACH - Most children who require admission for asthma are initially treated in the emergency department (ED), although some are admitted directly from clinicians' offices. Thus, inpatient treatment is typically a continuation of therapies and monitoring that were started in the ED (algorithm 1) [4]. Patients usually have received several albuterol treatments, often combined with ipratropium (children with an asthma exacerbation experience a lower risk of admission to the hospital if they are treated with the combination of inhaled short-acting beta agonists [SABAs] plus anticholinergic versus SABA alone [5]), systemic glucocorticoids, and supplemental oxygen, when necessary, before arrival to the inpatient unit.

Continuous therapy - We suggest that patients who have poor improvement after several inhaled beta agonist treatments or who require treatments more frequently than every two hours be treated with continuous beta agonist nebulization. Patients treated with continuous therapy who do not improve rapidly should be monitored closely for worsening respiratory status.

Children receiving continuous nebulized albuterol therapy who have increasing fatigue, increasing work of breathing, carbon dioxide retention, or worsening hypoxemia may need to be transferred to the ICU (intensive care unit) for closer monitoring and more aggressive treatment.

Magnesium sulfate - We suggest limiting the use of intravenous magnesium sulfate to patients with severe asthma exacerbations while in the ED or for those who require ICU care. Use in these settings is discussed in greater detail separately. We do not use nebulized magnesium sulfate, as it failed to show efficacy in one randomized trial."

The patient was treated appropriately in the ER for an acute episode of wheezing and difficulty breathing. The child has a history of poorly controlled asthma with four previous visits to the ER. His mother indicated that she did not have any albuterol at home. He was experiencing status asthmaticus with increased work of breathing which did not respond to four doses of bronchodilators. He was not stable enough to be safely discharged since he required albuterol every 2 hours.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The inpatient hospital stay is considered medically necessary for this patient.

The insurer's denial of coverage for the inpatient hospital stay is overturned. Medical necessity is substantiated.