Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Asthma exacerbation
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is overturned.

The patient has a medical history significant for patent ductus arteriosus status post repair and asthma who presented to the emergency department (ED) with a two-day history of cough, runny nose, and fever to 100.5 degrees Fahrenheit. She was initially seen in the clinic where she was noted to have decreased air entry and crackles, treated with a nebulized bronchodilator, and referred to the ED for further management with concern for pneumonia. Vital signs included a temperature of 101.5 degrees Fahrenheit, heart rate 138, respiratory rate 28, and 97% oxygen saturation on room air. She was in no acute distress, interacting appropriately with her caregiver, with moist mucous membranes wheezing, bilaterally diminished breath sounds, and non-focal neurologic exam. Laboratory evaluation was significant for an elevated C-reactive protein (CRP) 4.65, positive screen for parainfluenza type 3, and negative coronovirus disease (COVID) testing. A preliminary chest x-ray interpretation was negative for pneumonia. She was given ibuprofen and three albuterol treatments, but because she was still wheezing, she was admitted for further management of acute asthma exacerbation secondary to viral respiratory illness.
Admission orders included continued systemic steroids, continue albuterol every two hours titrating as tolerated, continue IV fluids, one dose of ceftriaxone, and follow-up culture results. She did not sleep well overnight due to dry cough, but was eating well. Her maximum fever was 103.2 degrees. She remained stable on room air. She remained on albuterol every two hours. Intravenous (IV) fluids were discontinued and she was able to drink well with good urine output. She was afebrile and tolerating albuterol every three hours with plans to wean further to every four hours. Pertussis labs were obtained and she was empirically started on azithromycin. An electrocardiogram was obtained because of persistent tachycardia revealing sinus rhythm. She was deemed stable for discharge home.
At issue is the medical necessity of an inpatient stay.

The acute inpatient stay was medically necessary and appropriate for this child. She could not have been safely managed at a lower level of care.
 
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. Asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough. There are a number of triggers for asthma and asthma-like conditions, including environmental allergies, weather changes, food allergies, and acute viral illnesses.
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 child with a history of asthma on no controller medications at home contracted a viral illness that resulted in an asthma exacerbation. When she presented to the ED, she was in sufficient distress that three back-to-back albuterol treatments were ineffective. Following admission, she remained on albuterol every two hours for more than 24 hours, with poor sleep the first night due to coughing and eventual concerns for possible pertussis in addition to her parainfluenza type 3 infection. Over the course of her hospital stay, she was able to slowly wean to treatments every four hours, a regimen that could reasonably be followed at home. Lack of hemodynamic instability and/or oxygen requirement in no way detracts from the significant of her atopic disease and degree of bronchospasms. Acute inpatient hospitalization was medically necessary and appropriate. She could not have been safely managed at a lower level of care.