Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

The patient is a child with a history of asthma who is maintained on daily inhaled arnuity ellipta. The child was sick for 3 days with a cough, fever and shortness of breath. The mother monitored the pulse oximeter in the home and when the level was low at 90% (percent) the mother decided to take the child to the Emergency Room (ER) for evaluation and treatment. When the child was evaluated in the ER, the child was noted to be in respiratory distress with belly breathing. The child was started on oxygen supplementation when the pulse oximeter reading was in the mid-80s. A chest x-ray showed left upper lobe pneumonia and the child was treated with Combivent, prednisone and ceftriaxone. The decision was made that this child needed to be admitted to the hospital for continued treatment and transfer was arranged for inpatient pediatric care.

In the ER, the child was noted to have bilateral retractions and wheezing. The pulse oximeter was 94% while the child was on 2 liters of oxygen. The child was started on albuterol and Decadron. When the symptoms did not improve, the child was started on continuous albuterol inhalation for one hour. The oxygen supplementation was increased to 4 liters when the pulse oximeter was 87% while the child was sleeping. After treatment in the ER, the child required ongoing oxygen supplementation and frequent albuterol nebulizer treatments. The decision was made to admit the child with a diagnosis of status asthmaticus and pneumonia for ongoing treatment with albuterol and oxygen supplementation.

The patient was treated appropriately in the ER for a cough, wheezing, and hypoxemia (low oxygenation). The chest x-ray was consistent with pneumonia and the child was started on antibiotics. The child was acutely sick with respiratory distress despite daily asthma preventive therapy. The child continued to have low oxygen saturation despite being treated with continuous albuterol for one hour and oxygen supplementation at 2 liters of pressure. The oxygen supplementation needed to be increased to 4 liters when the child was noted to have an oxygen saturation of 87%. This child with a history of asthma with a respiratory illness that resulted in increased work of breathing and hypoxemia despite treatment with antibiotics, continuous albuterol over one hour and prednisolone could not have been safely discharged home.

According to UpToDate, most children who require admission for asthma are initially treated in the emergency department (ED), although some are admitted directly from clinicians' offices. Thus, inpatient treatment is typically a continuation of therapies and monitoring that were started in the ED. Patients usually have received several albuterol treatments, often combined with ipratropium (children with an asthma exacerbation experience a lower risk of admission to the hospital if they are treated with the combination of inhaled short-acting beta agonists [SABAs] plus anticholinergic versus SABA alone), systemic glucocorticoids, and supplemental oxygen, when necessary, before arrival to the inpatient unit. Patients who were moderately to severely ill on arrival and who have little improvement after initial therapy with beta agonists and systemic glucocorticoids require hospitalization.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is substantiated.