Appeal type: Medical necessity
Decision: Overturned

Asthma
Inpatient Hospital

The patient is a male with a history of asthma who presented to the emergency department with respiratory distress.
He was well until 3 days prior to admission when he developed increased work of breathing. He had been receiving albuterol twice a day at home but began to require it every 2 hours. His mother also gave him oral corticosteroids that had been previously prescribed by his primary doctor. However, he continued to have coughing and wheezing. Of note, he was diagnosed with strep pharyngitis 9 days prior to presentation and was prescribed cefadroxil for 10 days.
His past history is significant for multiple prior emergency visits for asthma.
In the emergency department he was noted to have moderate respiratory distress. His lung exam was significant for diffuse wheezing with decreased air entry and moderate subcostal and suprasternal retractions. He was given 3 albuterol/Atrovent nebulized treatments as well as prednisone, magnesium sulfate, and a bolus of normal saline. However, following these treatments, he continued to have decreased air entry with retractions, and therefore he was started on continuous albuterol therapy. A chest x-ray and laboratory values were obtained. Following completion of the continuous albuterol, he was spaced to every 2 hour albuterol treatments and was admitted for further management of status asthmaticus.
On the hospital floors, he continued on every 2 hour albuterol therapy as well as amoxicillin and prednisone. Following admission, he remained afebrile and his respiratory status improved over time. He was successfully spaced to every 3 hour albuterol treatments by the morning, and then later that day to every 4 hour treatments. At that point he was felt to be stable for discharge, with continued treatment as an outpatient and follow-up with his primary doctor.

The health plan's determination is overturned.

Yes, the requested health service/treatment of inpatient stay was medically necessary for this patient.
 
This is a patient who presented with respiratory distress that was not responding to treatment with both bronchodilators and corticosteroids at home. He had several prior emergency visits for his asthma. In the emergency department he was noted to have respiratory distress, and required intensive management including further bronchodilator treatments, corticosteroids, and magnesium sulfate. Despite this, he continued to have significant symptoms and was placed on continuous albuterol and then every 2 hour albuterol treatment. He required hospital admission for continuation of these intensive treatments along with continuous cardiorespiratory monitoring.
The decision-making at the time of admission for this patient was consistent with his young age, the presence of status asthmaticus and respiratory distress that persisted despite intensive and appropriate treatments both at home and in the emergency department setting, and the need for continued intensive therapies with close monitoring for potential deterioration of clinical status. The level of therapy he needed would not have been appropriate for a lower level of care.