Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System-Asthma
Treatment: Inpatient Hospital Admission
The health plan denied the requested inpatient hospital admission as not medically necessary. The reviewer has overturned in whole the health plan's determination. 

The patient is a girl with mild persistent asthma who presented with acute respiratory distress from an allergic reaction and asthma exacerbation. The patient was well until the week prior to presentation when she had an asthma exacerbation. She was treated in the emergency department at that time and was sent home with corticosteroids and a new maintenance inhaler. She was taking Arnuity, but three days prior to presentation she noted swelling of her lips and cheeks. She also described tongue tingling, and she stated that the medication burned her throat and made her feel lightheaded. She also developed chest tightness. She was therefore brought to the emergency department for evaluation.
On examination in the emergency department, she was found to have lip swelling and bilateral expiratory wheezing. She was treated with Decadron and 3 Albuterol/Atrovent nebulized treatments. Laboratory values were drawn. Her symptoms improved slightly after these treatments, but she continued to wheeze. The patient was therefore admitted to the hospital due to concern for continued acute respiratory symptoms secondary to anaphylaxis and an asthma exacerbation, having just finished a course of steroids at home and having an allergic reaction to her controller medication.
In the hospital, she was found to have biphasic wheezing with tachypnea. She was treated with Albuterol every 3 hours, Ipratropium every 4 hours, and Solumedrol. A pulmonary consultation was requested. Her respiratory symptoms improved with that treatment, but she had decreased urinary output and was encouraged to drink more. She was felt to be stable for discharge to home, with an anaphylaxis asthma plan, Prelone, and Symbicort for her asthma.
At issue is the medical necessity for the inpatient hospital admission.

I overturn, in whole, the health plan's determination of medical necessity.

Yes, the requested health service/treatment of inpatient hospital admission was medically necessary for this patient. This is a young teenage girl who presented with anaphylaxis and an asthma exacerbation. She received appropriate and intensive treatments in the emergency department but continued to wheeze. She therefore required hospital admission for ongoing treatment with bronchodilators (initially every 3 hours), corticosteroids, and specialist consultation with close monitoring and additional treatments as needed.
The decision making at the time of admission for this patient was consistent with her young age, the presence of anaphylaxis with lip swelling and wheezing, and the persistence of respiratory symptoms despite appropriate treatments, along with the need for close monitoring for potential deterioration of clinical status.
According to the Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care Guidelines, 26th edition, Asthma, Pediatric, hospital admission is indicated for patients with an inadequate response to therapy including recurrence of symptoms within 3 hours of bronchodilator treatment. This patient continued to have wheezing despite emergency treatment, and initially required bronchodilators every 3 hours, which warrants hospital admission.