Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status asthmaticus

Treatment: Inpatient hospital admission 

The insurer denied coverage inpatient hospital admission. The denial was upheld.

This patient is a female child who arrived in ED and was admitted with status asthmaticus. She had a single previous episode of wheezing in the past and she has allergic rhinitis. She was seen at an urgent care center, treated with a nebulized bronchodilator that resulted in improvement but not resolution, so she was transferred to an ED where she received albuterol+ atrovent nebs x 3 and an additional albuterol neb treatment in addition to dexamethasone orally. The vital signs in ED- it is unclear what time they were actually recorded - included heart rate of 145, respiratory rate 28, pulse oxygen 94%on room air. The same ED note, indicates patient remained tachypneic with retractions after albuterol x3.  She had a white count of 16.7 but a chest X-ray did not show a focal infiltrate. There is a note indicating admission for observation and albuterol every 2 hrs. The ED note also indicates no need for oxygen supplementation. Subsequently, she was treated with azithromycin, ceftriaxone, and magnesium which were also given because of continued wheezing. 

There is a note which indicates increased respiratory distress. Questionable stridor with bilateral inspiratory and expiratory wheezes and minimal air movement to left lower base. A second intravenous line was started.  Due to heart rate of 170+ she was switched to xopenox. A chest x-ray done showed no infiltrate. A blood gas labeled as venous was obtained that showed hyperpneic respiratory alkalosis (pH 7.43, pCO2 26, pO2 of 85.). Vital signs for several hours show the patient on oxygen 2 liters/min by nasal cannula with a pulse oximetry of 95-96%. There is no documentation of any desaturation and as noted the repeat chest x-ray showed no infiltrate. The records provided do not clearly indicate how often she required and received inhaled bronchodilators after admission. After several hours ALS arrived and transferred the patient.

The health plan has denied inpatient admission indicating that a lower level of care would have been sufficient to meet this child's medical needs. 

The documentation provided is insufficient to establish the need for an acute, inpatient level of care. This child failed management in the ER with frequent use of inhaled bronchodilators and oral steroids. Based on the records provided, she could have been managed with an observational level of care overnight.
      
The documentation provided does not clearly indicate that this child had ongoing wheezing, difficulty breathing, or need for frequent albuterol after the time she was in the emergency room. There are no MD progress notes. The data in her clinical status can be pieced together from the vital signs records, nursing records. The discharge summary is primarily a repeat of the ED note with a brief description as noted above of why the patient was transferred. The objective data including chest x-ray, and level of oxygenation do not support the need for acute inpatient care.

The documentation provided does not establish medical need for an acute, in patient level of care. Thus, the health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.