Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a medical history significant for asthma and was brought to the emergency department (ED) via Emergency Medical Services (EMS) for management of worsening respiratory distress. One day prior to admission he developed congestion, cough, and a fever to 101 degrees Fahrenheit (F). He was treated initially with acetaminophen, and because of worsening distress, was given one inhaled albuterol treatment without significant improvement. He continued to worsen, so EMS was contacted. En route to the ED, he was treated with epinephrine, Decadron, and two DuoNebs. The oxygen saturation was 92% prior to arrival. Vital signs included temperature 101.9 degrees F, heart rate 141, respiratory rate 50, and blood pressure 120/77. The examination was significant for respiratory distress with nasal flaring, accessory muscle use, retractions, wheezing with rhonchi, tachycardia, and non-focal neurologic exam. Laboratory evaluation was significant for mild hypokalemia (3.4), mild metabolic acidosis (CO2 19), normal white blood cell count (WBC) count (10.8 thousand [K]), coronavirus (COVID) negative. Blood and throat cultures were obtained. A chest x-ray was unremarkable. He was treated with DuoNeb, magnesium, ceftriaxone, albuterol, a normal saline bolus, and acetaminophen. He remained symptomatic so was admitted for further care. Admission orders included regular diet, continuous pulse oximetry, albuterol every three hours, enteral steroids, and IV (intravenous) fluids. Ceftriaxone was not continued. Over the course of the first hospital day, the nasal flaring and retractions resolved but he was still wheezing and developed bilateral crackles. Zithromax was started. By the second hospital day, he was tolerating albuterol every four hours, he was afebrile, and stable in room air. He was deemed stable for discharge home despite ongoing mild wheezing.
At issue is the medical necessity of an inpatient stay.

An inpatient stay was not medically necessary. Asthma is an inflammatory process characterized by airway obstruction due to airway hyper-responsiveness, bronchospasm, airway inflammation, and mucus production. Gas exchange abnormalities are due to ventilation/perfusion mismatch, as a result of atelectasis and airway over-distention. Status asthmaticus is defined as "severe asthma that fails to respond to inhaled beta-agonists, oral or intravenous steroids, and requires admission to the hospital for treatment." (1) Asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough. "Despite advances in asthma management, acute exacerbations continue to be a major problem in patients ...our review findings support the importance of controlling persistent asthma ...early episodic intervention appeared to be crucial in preventing severe attacks and future exacerbations." (2)
In the ED, 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, admission is necessary.
This young male child with history of asthma presented to the ED in status asthmaticus, with significant increased work of breathing and bronchospasm. Despite aggressive treatment in the ED, he remained symptomatic prompting hospitalization. While he required treatment beyond what could be provided at home, he was overall hemodynamically stable with no oxygen requirement and no evidence of impending respiratory failure. He did not require acute inpatient admission and could have been safely managed at a lower level of care.