Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System/Asthma. 
Treatment: Inpatient Hospital Admission. 

The health plan denied the requested inpatient hospital admission as not medically necessary. The health plan's determination is overturned. 

The patient is a boy with a history of asthma who presented with fever, cough, and respiratory distress. He was well until 3 days prior to presentation when he developed a cough. The cough progressively worsened over time, and he also began to complain of lower abdominal pain, as well as leg pain. On the morning of presentation, he had a fever to 100.2 Fahrenheit (F). and developed wheezing and respiratory distress. He was therefore, brought to the emergency department for evaluation. 

In the emergency department, the patient was described as ill appearing and was found to have respiratory distress with wheezes and retractions. His oxygen saturation was 95% and his heart rate was 164 beats per minute (bpm) and his respiratory rate was 40/minute. He was febrile with a temperature of 100.2 F. The patient was given Albuterol/Atrovent nebulized treatments, as well as Dexamethasone with some improvement. Laboratory values were drawn and a chest x-ray was obtained. He continued to have wheezing and tachycardia, and therefore, he was admitted to the hospital for continued treatment and monitoring. 

In the hospital, the patient was initially prescribed Albuterol every 3 hours and then was weaned to every 4 hour treatments, with oxygen by nasal cannula and then a non-rebreather. Later he was weaned to room air. The patient was able to speak full sentences, was drinking well, and had only mild wheezes, and therefore, he was felt to be stable for discharge to home with follow up as an outpatient. 

The inpatient hospital admission is under review for medical necessity.

I overturn, in whole, the health plan's determination of medical necessity.

Yes, the requested health service/treatment of an inpatient hospital admission was medically necessary for this patient. 

This is a young boy who presented with wheezing and respiratory distress. He continued to have wheezing and tachycardia despite appropriate and intensive treatment in the emergency department, and initially required every 3-hour bronchodilator treatments in the hospital. While he improved quickly, this level of care required an inpatient setting.
The decision making at the time of admission was consistent with his young age, the presence of respiratory distress and wheezing that continued despite appropriate and intensive treatment in the emergency department, and the need for ongoing intensive treatments, including initially every 3 hours bronchodilator treatment and supplemental oxygen, along with close monitoring for potential deterioration of clinical status.
Inpatient admission is necessary for patients with asthma who continue to have significant symptoms after emergency treatment, and who require frequent bronchodilator treatments, more often than every 4 hours. 

This patient continued to wheeze despite emergency treatment, and initially required bronchodilators every 3 hours as well as supplemental oxygen, along with continuous monitoring with additional therapies as needed.