Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status Asthmaticus
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is: Overturned

The patient is a male who presented to the emergency department with concerns of shortness of breath. Pertinent history included asthma, tobacco abuse, and multiple gun-shot wounds status/post (s/p) tracheostomy. No history of intubation for asthma or Intensive Care Unit (ICU) admission for asthma.

Three nebulizers, dexamethasone, and intramuscular epinephrine were administered with no improvement. bi-level positive airway pressure (BiPAP) was initiated. Another intramuscular epinephrine was administered. The patient was unable to tolerate BiPAP and thus was intubated with etomidate and rocuronium. The intensivist had an impression of status asthmaticus. A fentanyl infusion and ketamine infusion were initiated following intubation. Additionally, a nicardipine infusion was initiated for severe hypertension. Thereafter, the patient self-extubated without subsequent distress. A non-rebreather was initiated but the patient removed that as well. Oxygen saturation thereafter was 95-98% on room air. The patient ultimately left against medical advice. The subject under review is the medical necessity for the inpatient admission.

The health plan's determination is overturned.

The inpatient admission was medically necessary for this patient.

Based on the clinical documentation provided, evidence-based literature and standards of care, acute inpatient level of care was indicated as medically necessary for the entire admission.

Pollart et al. note asthma exacerbations can be classified as mild, moderate, severe, or life threatening. Criteria for exacerbation severity are based on symptoms and physical examination parameters, as well as lung function and oxygen saturation. Mild is classified as dyspnea only with activity and with a peak expiratory flow (PEF) greater than (>) 70% of predicted or personal best. Moderate is classified as dyspnea interfering with usual activity and a PEF 40 to 69% of predicted or personal best. These types usually require office or emergency department evaluation. Severe is classified as dyspnea at rest, interferes with conversation, and a PEF less than (<) 40% of predicted or personal best. These patients usually require an emergency department visit with likely hospitalization. In the ambulatory and emergency department settings, the goals of treatment are correction of severe hypoxemia, rapid reversal of airflow obstruction, and reduction of the risk of relapse.

The patient had a history of asthma and presented with visual respiratory distress, diffuse wheezing and accessory muscle use. Tachycardia, tachypnea, and elevated lactic acid were noted. Emergency department treatment included four nebulized bronchodilators, multiple intravenous corticosteroids, and two intramuscular epinephrine injections. Despite this, acute respiratory distress persisted and a BiPAP was initiated. The patient was unable to tolerate the BiPAP and continued to have acute respiratory distress. Thus, the patient was intubated and placed on mechanical ventilation for concerns of status asthmaticus. The patient leaving against medical advice does not invalidate the need for inpatient services.

Moreover, clinical indications for admission to inpatient care were met. The patient, after extensive medical management, required ventilator support for presumed status asthmaticus.[2]