Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma Exacerbation.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is overturned.

According to the documentation submitted, this is a child with a history of asthma. The patient presented to the emergency room (ER) with complaints of a two day history of a cough and nasal congestion. The patient was admitted for a severe asthma exacerbation. During the admission the patient was given combo nebulization, dexamethasone, and albuterol. The patient was discharged after a period of hemodynamic stability. 

The insurer has denied coverage for the inpatient hospital as not medically necessary. In a Final Adverse Determination letter, they stated that the patient has asthma. Test results revealed an asthma attack. There is no indication that the patient did not get better after observational treatment. The requested admission is denied based on Milliman Care Guidelines 26th Edition using the guideline of Asthma, Pediatric ORG: P-60 (ISC). 

This is a child with a history of asthma and a previous admission for wheezing. The patient had a respiratory illness with congestion, coughing and decreased oral intake for 2 days. The patient had been prescribed albuterol for home use in the past and was administered 4 doses in the home but when the patient did not improve, and their breathing became more labored, the patient's father brought the patient to the emergency room (ER) for medical evaluation.

In the ER, the patient was noted to have respiratory distress with increased work of breathing. On physical examination the patient had retractions, bilateral wheezing and prolonged expiratory phase of respiration. The patient was treated with albuterol and Atrovent on 3 occasions, Decadron and magnesium sulfate. Following treatment in the ER, the patient was still noted to have substernal retractions. A respiratory viral panel was positive for respiratory syncytial virus (RSV) and a chest x-ray was significant for atelectasis of the right upper lobe and a silhouette sign of the left lower lobe border consistent with an infiltrate of the lingular lobe. 

The history indicated that the mother had died from a COVID virus infection, and the father was the legal guardian. Child protective services had been monitoring this child in the past and when the father left the child in the ER during acute treatment for asthma it was determined that child protective services would again be contacted. When the child continued to have wheezing and increased work of breathing following treatment in the ER the decision was made to admit the patient with a diagnosis of status asthmaticus for ongoing treatment with albuterol, every 2 hours. 

The patient was treated appropriately in the ER for a cough, tachypnea and wheezing. The medical record indicates that the child had a history of a previous admission for asthma. The child continued to have respiratory distress after treatment in the ER and required ongoing treatment with albuterol every 2 hours. The decision to admit to the hospital for ongoing treatment with albuterol every 2 hours was consistent with the standard of care for status asthmaticus. There was also concern that the father left the child unattended in the ER and child protective services were contacted to reopen the previous reported case for this child. This child with a history of asthma and ongoing wheezing and retractions was not stable enough to be discharged safely to the home and admission to the hospital was medically indicated.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is substantiated.