Appeal type: Medical necessity
Decision: Overturned

The patient was brought by ambulance to the emergency department (ED) with increased work of breathing. He had a prior history of wheezing associated with respiratory illnesses and had received oral steroids 5-6 times in the preceding six months for exacerbations with upper respiratory infections (URI's). He had seen his physician two days before and was prescribed Amoxicillin for otitis media.
He had URI symptoms for one week and one day of wheezing with increased work of breathing that worsened despite home administration of inhaled Albuterol with a mask/spacer every 1.5-2 hours and one dose of oral steroids.
On arrival at triage, his respiratory rate (RR) was 60/minute, with an oxygen saturation of 93%. He was described as being in moderate respiratory distress with increased work of breathing, belly breathing, and bilateral wheezes. He was started on oxygen and nebulizer treatments. A swab for respiratory viruses was positive for rhinovirus. A chest x-ray (CXR) was positive for right middle lobe consolidation. He was treated with three Albuterol/Atrovent nebulizer treatments, magnesium (Mg), and Methylprednisone; he had some reduction in his respiratory rate, but continued to have significant wheezing, so he was admitted to the Pediatric Intensive Care Unit (PICU) for continuous Albuterol treatments.
On admission to the PICU, his RR was 33/minute and his saturation was 100% on 2 liters of oxygen by nasal canula. He was described as awake and alert, well hydrated and perfused, without retractions or other signs of respiratory distress; his lung exam showed prolonged expiratory phase and intermittent scattered wheezes.
In the PICU he received every 1 hour Albuterol and 2 liters of oxygen, which was quickly spaced to every 3 hours and he was transferred to the regular pediatric floor. On the floor, he stayed well saturated on room air and received every 4 hours Albuterol. He was sent home the next day on Amoxicillin for otitis, Albuterol for wheeze, steroids to complete a five day systemic course, and inhaled steroids. The health plan's determination is overturned.
The inpatient hospital admission was medically necessary. This patient had a past history of wheezing-associated respiratory illnesses with 5-6 courses of oral steroids in the preceding six months. He presented with an exacerbation of one day duration in the context of another URI (rhinovirus positive), with worsening tachypnea and wheeze at home despite Albuterol administration every 1.5-2 hours per mom and a single dose of oral steroids. In the ED, he had tachypnea, distress, and wheezing with an oxygen saturation of 93%. He was put on oxygen and given appropriate medications in the ED which lessened his respiratory rate, but he continued to have significant wheezing.
The patient had a failure of outpatient management. Typically, parents are instructed to give Albuterol no more frequently than every four hours. If a patient is needing treatment more frequently than that, it is typically not considered safe to do so at home, so presenting to the emergency department was appropriate.
The patient then had a failure of ED and initial observation management. He had some improvement in respiratory rate following aggressive ED management--three nebs, intravenous (IV) steroids, IV fluid, Mg, but he still had significant wheezing and remained on oxygen. It was appropriate to admit him to the hospital for acute care, initially receiving every 1 hour Albuterol in an ICU setting. Over the course of the overnight hospitalization, he was able to be weaned to every 2 hour then every 3 hour Albuterol and off oxygen, at which point it was appropriate to transfer him to the floor, where he continued to improve and was eventually discharged.