Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath/Asthma.
Treatment Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to an outside emergency department (ED) with a two-day history of fevers and increased work of breathing. He was treated with three DuoNebs, dexamethasone, magnesium, intravenous (IV) hydration, and antipyretics. He continued to require frequent albuterol treatments every two hours so was transferred to the closest Pediatric Intensive Care Unit (PICU) for further care. Vital signs included temperature 37.5-38.1 degrees Celsius, heart rate 137-180, respiratory rate 30-46. Examination was significant for no apparent distress, moving air well (in the PICU) with mild wheezing bilaterally at the bases immediately after an albuterol treatment, good perfusion, and a non-focal neurologic exam. Laboratory evaluation was significant for leukocytosis and rapid respiratory panel positive for enterovirus/rhinovirus. A chest x-ray was unremarkable. Admission orders included antipyretics as needed, albuterol every two hours, regular diet for age, and maintenance IV fluids. He had no supplemental oxygen requirement. The albuterol was weaned to every four hours in the morning, he was doing well with his diet, and he remained afebrile. He was deemed stable for discharge home later that day.
At issue is the medical necessity of an inpatient stay.

No. The requested acute inpatient admission was not medically necessary for this young male patient admitted with viral infection and reactive airways disease. He could have been safely and appropriately managed at a lower level of care.
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, as a result of atelectasis and airway over-distention. Reactive airways disease is similar in presentation to asthma early in life, often occurring in response to acute viral infection in predisposed atopic individuals. Presenting symptoms and acute management strategies are basically the same.
In the ED, the 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, admission is necessary.
This young child presented with a fever and increased work of breathing, testing positive for enterovirus/rhinovirus, consistent with reactive airway disease. He responded well to the cocktail of bronchodilators, corticosteroids, and hydration. Over the course of the first day, he was able to successfully wean from treatments every two hours to treatments every four hours. Overall, he remained hemodynamically stable with no supplemental oxygen requirement and no evidence of impending respiratory failure. He did not require acute inpatient admission and could have been safely managed at a lower level of care.