Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma 
Treatment: Inpatient Hospital Stay 
The insurer denied the inpatient hospital stay. 
The determination is upheld. 

The patient has a medical history significant for obesity (with elevated triglycerides), eczema, and moderate persistent asthma, with prior pediatric intensive care unit (PICU) admission, on routine home medications (albuterol, Symbicort) who presented to the emergency department (ED) with a one-day history of shortness of breath and cough. She was given her routine medications before bed but then awoke in the middle of the night wheezing. She was given nebulized albuterol. After that, they decided to go to the emergency department (ED). Additional complaints included chest pain and rhinorrhea. She had no fevers or known ill contacts. The examination was significant for a non-toxic appearance, wheezing throughout, decreased breath sounds at the bases, no retractions, moist mucous membranes, and a non-focal neurologic exam. She was treated with CombiNebs, prednisolone, and ibuprofen to help with the chest pain. Upon re-evaluation, she was found to have persistent wheezing. She was transitioned to albuterol every two hours and admitted for ongoing treatment. Rapid influenza, respiratory syncytial virus (RSV), and coronavirus (COVID) tests were negative.

Admission orders include albuterol every two orders, spacing apart as tolerated, with consideration for transitioning from nebulizer to metered dose inhaler (MDI) with spacer, ongoing steroids for total five days, continued home medications, respiratory scoring per asthma pathway, continuous pulse oximetry if supplemental oxygen is needed, regular diet, consideration for magnesium, and pharmacy consultation for asthma education. She improved and was able to tolerate treatments spaced out slowly to every four hours. She was deemed stable for discharge. 

An inpatient hospital stay was not medically necessary. 

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. There are many possible triggers including exposure to allergens and upper respiratory viral infections. Asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough. 

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 female child with moderate persistent asthma presented with an acute asthma exacerbation and status asthmaticus refractory to bronchodilator treatments at home. She was treated aggressively in the ED, with persistent wheezing as evidence of ongoing bronchospasm. While it was reasonable and appropriate to continue frequent albuterol treatments in the hospital setting, she was overall hemodynamically stable with no indication of impending respiratory failure. She did not require acute inpatient hospital admission and could have been safely managed at a lower level of care.