Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
Treatment: Inpatient hospital admission
The health plan denied Inpatient hospital admission.
The determination is Upheld.

The patient is a male child with medical history of asthma who was taken to the emergency department (ED) via Emergency Medical Services (EMS) with a two-day history of cough and shortness of breath. Albuterol treatments at home were ineffective. He received additional albuterol en route. He had been exposed to dust from home renovation, a trigger for a past asthma exacerbation. His vital signs included a temperature of 36.9 Celsius, a heart rate of 126 beats per minute (bpm), a respiratory rate of 22 per minute, and an oxygen saturation of 97 percent (%) in room air. Examination was significant for no acute distress, able to speak in full sentences without pause, mild inspiratory and expiratory wheezing, active and climbing on the furniture, moist mucous membranes, and non-focal neurologic exam. He was treated with a DuoNeb and Decadron, and because of persistent wheezing, he was then given albuterol, magnesium, and a fluid bolus. Laboratory evaluation included a venous blood gas with a potential hydrogen (pH) of 7.34 and partial pressure of carbon dioxide (pCO2) of 40.8, a metabolic panel with a glucose of 145 and carbon dioxide (CO2) of 21, and a complete blood count (CBC) with a white blood cell (WBC) count of 14.4 with 73% (percent) neutrophils. The rapid viral screen was negative. He was subsequently admitted for management of persistent wheezing. Admission orders included intravenous (IV) fluids, albuterol every three hours, prednisolone twice daily, and antipyretics as needed. Overnight, he was able to tolerate less frequent albuterol treatments. He remained stable in room air and was breathing more easily and comfortably. He was deemed stable for discharge home to follow-up with his pediatrician in two to three days.
At issue is the medical necessity of the inpatient hospital admission.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of inpatient hospital admission was not medically necessary for this patient.
Asthma is an inflammatory process characterized by airway obstruction due to airway hyper-responsiveness, bronchospasm, airway inflammation, and mucus production. Gas exchange abnormalities are due to ventilation/perfusion mismatch from atelectasis and airway over-distention. There are many possible triggers including exposure to allergens and upper respiratory viral infections. Unfortunately, asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough.
In the ED (emergency department), primary management strategies include correction of hypoxia, rapid improvement of airflow obstruction, and prevention of progression. This is achieved with supplemental oxygen, bronchodilators, and steroids. Fluid hydration may also be necessary. For patients with moderate to severe exacerbations that do not respond to such intensive therapy in the ED (emergency department), admission is necessary.
This young male child with history of asthma on home controller medications experienced exacerbation following exposure to a triggering agent. He was treated aggressively in the ED (emergency department) with multiple doses of bronchodilators, magnesium, corticosteroids, and IV (intravenous) fluids, but continued to experience wheezing. While it was reasonable to monitor in the hospital for improvement in bronchospasm, he was overall hemodynamically stable with no need for supplemental oxygen, no significant dehydration, and no evidence of impending respiratory failure. He did not require acute inpatient admission and could have been safely managed at an alternate level of care.