Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of breath, fever, cough 
Treatment: Inpatient admission 

The insurer denied the inpatient admission. The denial is overturned. 

Yes, the inpatient admission is "medically necessary". 

The patient is a female child born prematurely as a 32-week-gestation twin with history of chronic lung disease and reactive airway disease and with multiple ED visits and floor admissions followed by Pulmonology that presented to the ED with one-day history of fever, cough, and shortness of breath. Rapid RSV (respiratory syncytial virus) had been performed at another facility and was negative. Vital signs included temperature 37.5, heart rate 135, and respiratory rate 42 with 96% saturation in room air. 

Examination was significant for no distress, moist mucous membranes, regular heart rate and rhythm, tachypnea, mild wheezing, benign abdomen, and non-focal neurologic exam. She was treated with prednisolone, magnesium, dexamethasone, albuterol, and a normal saline bolus. 

The patient was admitted for ongoing tachypnea and belly breathing despite treatments in the ED, likely bronchiolitis and acute exacerbation of asthma. Admission orders included IV fluids at maintenance, regular diet for age, nebulized saline every three hours, albuterol every three hours, continued enteral steroids twice daily, and Pulmonology consultation. Labs were subsequently obtained significant for thrombocytosis (443K) and hyperglycemia (glucose 153). Albuterol was weaned to every four hours as her respiratory distress resolved. Throughout her stay, she maintained good intake and urine output. She was deemed stable for discharge to complete a course of corticosteroids, continue albuterol every four hours for the next five days, follow-up with the pediatrician in two to three days, and follow-up with Pulmonology in two weeks. 

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. Status asthmaticus is defined as "severe asthma that fails to respond to inhaled beta-agonists, oral or intravenous steroids, and requires admission to the hospital for treatment." (1) Unfortunately, asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough. "Despite advances in asthma management, acute exacerbations continue to be a major problem in patients; our review findings support the importance of controlling persistent asthma; early episodic intervention appeared to be crucial in preventing severe attacks and future exacerbations." (2) 
 
In the ED, 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 born prematurely with history of chronic lung disease and subsequent reactive airway disease/asthma, as well as frequent exacerbations requiring visits to the ED and hospitalizations, presented with signs and symptoms consistent with another acute asthma exacerbation following URI (upper respiratory infections) symptoms. While she had no oxygen requirement and had no issues with dehydration, she required the aggressive management of an inpatient hospitalization for her degree of respiratory distress, including frequent assessments, saline and albuterol breathing treatments, pulse oximetry, and Pulmonology consultation. She could not have been safely managed at a lower level of care. The acute inpatient admission was medically necessary for all days in question.