Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath and Wheezing
Treatment: Inpatient admission
The health plan denied coverage of the Inpatient admission.
The denial is upheld.

The patient is a female child with medical history significant for asthma that presented to the emergency department via Emergency Medical Services for evaluation of difficulty breathing. She had been discharged the day prior from a three-day hospital stay for asthma exacerbation. She was sent home with albuterol every four hours, Symbicort twice daily, and Zyrtec daily. She had been seen earlier in the day in the Pulmonary Clinic and no changes were made to her management. She was treated with albuterol at noon and after had two episodes of vomiting. She began complaining of shortness of breath for which she was given an additional albuterol treatment. She began having a panic attack with hyperventilation, screaming, and crying that she could not breathe. Her mother contacted Emergency Medical Services and she was transported to the emergency department. 

En route, the patient was treated with epinephrine, dexamethasone, and two combivent trreatments. The patient's vital signs included temperature 38.4, heart rate 93, respiratory rate 22 with 100% saturation. The patient's examination was significant for tachypnea, prolonged expiration, respiratory distress, mild wheezing, bilateral decreased air entry, and non-focal neurologic exam. Her laboratory evaluation revealed normal complete blood count (CBC) of 10.1 thousand, left shift with 81% neutrophils, and unremarkable metabolic panel. The patient was treated with three nebulized albuterol, one Duoneb, parenteral magnesium, and a normal saline bolus prior to admission for ongoing management of acute asthma exacerbation likely triggered by seasonal allergies. Admission orders included regular diet, albuterol every three hours, Tylenol and Motrin as needed for fever, Pulmonology consultation, and asthma education. The patient did well overnight with resolution of respiratory distress. She was deemed stable for discharge the following day to complete a five-day course of steroids and continue albuterol every four to six hours.

The patient could have been safely managed at a lower level of care like observation.

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. Asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough. 

In the 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 emergency department, admission is necessary.

This child with history of asthma and recent admission for asthma exacerbation discharged home the day before presented with acute asthma exacerbation complicated by a panic attack. She was treated with bronchodilators, steroids, fluids, and magnesium but remained symptomatic. While it was reasonable and appropriate to monitor the patient in the hospital for improvement or progression of symptoms, she was overall hemodynamically stable with no sign of impending respiratory failure and no oxygen requirement, she did not require acute inpatient admission. She could have been safely and appropriately managed at an observation level of care, including Pulmonary consultation.