Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male child with past medical history significant for asthma. He was brought to the ER (emergency room) due to shortness of breath and wheezing while staying with his grandmother. The grandmother did not have any of his asthma medications. Per the grandmother, the patient woke up in the middle of the night with shortness of breath. She brought him to the ER (emergency room) due to not having his albuterol. The patient had runny nose and cough for one week. There was no reported fever or other symptoms. He is a former 28-week premature infant. His home medications included Albuterol and Qvar. In ER (emergency room), the patient's vitals were BP (blood pressure) 90/46, afebrile, HR (heart rate) 125, RR (respiration rate) 22, and pulse oximetry 98% on room air. On exam, the patient was in no acute distress. No congestion or rhinorrhea was noted. No tachypnea, regular rate and rhythm, 
expiratory wheeze in all lung fields, good air entry, and no retractions were noted. The patient's assessment included acute asthma exacerbation without status asthmaticus. Low suspicion for pneumonia, pneumothorax or acute valvular failure. He had three ER (emergency room) visits in the last year for asthma, no ICU (intensive care unit) admissions. The plan was to trial bronchodilator and steroids and reassess. The patient was given three DuoNebs (and Decadron in the ER). After the third DuoNeb, he continued to wheeze and experience tachypnea. 
On history and physical exam, good air entry, no added sound was noted. RR (respiration rate) was 22, HR (heart rate) 125, BP (blood pressure) 90/46, and oxygen saturation 98% on room air. 
The patient's VBG (venous blood gas) was noted 7.31/41/42/20.8/-5.3. BMP (basic metabolic panel) revealed Na (sodium) 151, K (potassium) 3.6, Cl (chloride) 115, CO2 (carbon dioxide) 21, Anion Gap 18. The assessment in the history and physical noted tachypnea, on room air. 
On the next day the patient was discharged home. He was spaced to every-4-hours albuterol. Repeat BMP (basic metabolic panel) showed Na (sodium) 144. His tachypnea improved. 
The health plan denied coverage of the inpatient admission as not Medically Necessary. The denial is being appealed. 

The Inpatient Hospital Admission was not medically necessary. 

The patient is a young male with history of asthma. He was staying at his grandmother's house but did not have his asthma medication, albuterol, with him. He came to the emergency room due to breathing fast and wheezing. He had upper respiratory symptoms for about one week. The patient received three treatments of albuterol/ipratroprium in the first hour. After repeat exam he was found to have wheezing and tachypnea. Further, the history and physical notes he had clear breath sounds, no extra sounds. This patient, based on the timing of medications given, and admission history and physical, could have continued at observation level of care. There is lack of documentation other than in the emergency room for tachypnea and wheeze in this patient that indicated admission was required. Further when decision was made to admit the patient, the patient was not aggressively treated and there was a significant delay in continuing treatments.