Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System-Asthma.
Treatment: Inpatient hospital stay.
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination. 

The patient is a child with no significant medical history that presented to the emergency department (ED) with a one-day history of mid-sternum chest pain associated with productive cough, shortness of breath, and sore throat. She had no fevers. Vital signs included temperature 37.2, heart rate 131, respiratory rate 20, and saturation 91% in room air. Examination was significant for acute distress with decreased breath sounds, wheezing, and rales, ill appearance, tachycardia, 2+ tonsils, and non-focal neurologic exam. Laboratory evaluation was significant for metabolic acidosis, mild hypokalemia, and normal white blood cell (WBC) count with left shift. Chest x-ray revealed minimal peribronchial cuffing consistent with viral bronchiolitis or reactive airway disease with no lung consolidation. She was treated with enteral Decadron and three DuoNeb treatments. Oxygen saturation remained in the low 90's so she was treated with additional albuterol, magnesium sulfate, and an IV (intravenous) fluid bolus. She continued to wheeze with poor air entry and bibasilar crackles. She was given a dose of azithromycin, an additional dose of albuterol, and admitted for further care. Admission orders included regular diet, azithromycin, albuterol every three hours, and Tylenol and Motrin as needed. Overnight, she remained afebrile and hemodynamically stable, with no supplemental oxygen requirement and no increased work of breathing. She was deemed stable for discharge. Because of a strong family history of asthma, she was discharged with a prescription for albuterol and prednisolone.

No, acute inpatient admission was not medically necessary for this child. Chest pain is a reasonably common complaint in the pediatric population. In terms of referral to pediatric cardiology, it ranks second only to heart murmurs. The most common cause is idiopathic, occurring in up to half of cases. Other causes include pulmonary, musculoskeletal, gastrointestinal, and psychological. Actual cardiac causes are present in less than 5% of cases. Most children have normal physical exam findings. Interventions depend upon etiology: bronchodilators for reactive airways disease, anti-reflux medications for gastroesophageal reflux, and non-steroidal anti-inflammatory medications for musculoskeletal pain.
This child presented with chest pain in conjunction with productive cough, increased work of breathing, and significant wheezing upon exam. She was treated for atypical pneumonia with reactive airway disease in the setting of positive family history for asthma. While it was reasonable for this child to remain in the hospital to monitor wheezing while providing inhaled bronchodilators and enteral antibiotics, she was overall hemodynamically stable with no oxygen requirement and no indication of impending respiratory failure. She did not require acute inpatient admission and could have been safely managed at a lower level of care.