Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever; respiratory distress.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is a school aged male child with medical history significant for mild intermittent asthma, as well as seasonal and environmental allergies. He presented to the ED (emergency department) with fever and respiratory distress. His cough started earlier in the day, worsened over time over time, and was unresponsive to albuterol. The patient's vital signs included temperature 36.5, heart rate 128, respiratory rate 33 with 95% saturation in room air. Examination was significant for moderate respiratory distress with grunting and nasal flaring, moist oral mucosa, poor aeration with scant wheezing, and non-focal neurologic exam. He was started on the asthma pathway with three Combivent treatments and a dose of dexamethasone. Aeration was improved and he could speak in full sentences, reporting that he was feeling better. However, despite these treatments, he continued to have difficulty, with tachypnea, grunting, and chest tightness. An IV (intravenous) line was placed for fluid bolus and lab studies. He was given a dose of magnesium and started on continuous albuterol. Chest x-ray was obtained revealing increased perihilar markings bilaterally. Subsequently, he was no longer able to speak in full sentences. He was given azithromycin and Ceftriaxone for possible pneumonia, weaned albuterol to every two hours, and admitted to the pediatric floor for further management.
Admission orders included albuterol every two hours weaning as tolerated, Pulmonary consultation, no further antibiotics (following formal x-ray report), encourage outpatient Allergy appointment, continue steroids, GI (gastroenterology) consultation (had outpatient appointment that day), and diet as tolerated. Viral respiratory panel was positive for human rhinovirus/enterovirus. He was able to wean to every three hours. Over the course of that night, he was able to wean to treatments every four hours. Pulmonary consulted with recommendations to discharge on Asmanex with follow-up appointment in a week. He was deemed stable for discharge on the second day to complete his course of steroids and continue albuterol every four hours.

The Inpatient Hospital Admission was not medically necessary.

Asthma is an inflammatory process characterized by airway obstruction due to airway hyper-responsiveness, bronchospasm, airway inflammation, and mucus production. There are many possible triggers including exposure to allergens and upper respiratory viral infections. Unfortunately, asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough.
In the ED (emergency department), 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 (emergency department), admission is necessary.
This young male child with known history of asthma presented to the ED (emergency department) after failing treatment at home with bronchodilators. He was treated aggressively with intermittent and continuous albuterol, Atrovent, parenteral steroids, magnesium, and fluids. Although he improved somewhat, he continued to display signs and symptoms of significant bronchospasm and respiratory distress. While it was not unreasonable to monitor him in the hospital while providing 
frequent bronchodilator therapy, awaiting sufficient resolution, he was overall hemodynamically stable. He did not require supplemental oxygen, he was not in impending respiratory failure, and he was able to tolerate fluids by mouth. He did not require acute inpatient admission and could have been safely managed at a lower level of care.