Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma and Pneumonia. 
Treatment: Inpatient Admission. 
The insurer denied coverage for the inpatient admission. 
The denial is overturned. 

This is a teen male with a history of asthma and a respiratory illness for 4 days. The patient had been born at 25 weeks gestation and spent 3 months in the neonatal intensive care unit (NICU). The last hospitalization for asthma was as a toddler. There were 2 previous Emergency Room (ER) visits during this illness: the first was 4 days prior to the admission. At this ER visit the patient was diagnosed with pneumonia when a chest x-ray showed a right upper lobe infiltrate. He was discharged with a prescription for antibiotics and prednisone. The mother was not able to obtain the medication to administer to the child. The second was on the same day as the hospitalization when he was continuing to cough and had developed shortness of breath. Following this ER visit the patient had a coughing spell after leaving the ER and he was experiencing shortness of breath. The patient was unable to walk home because of shortness of breath which resulted in the mother retuning to the ER for further treatment. 

In the ER, he was noted to have a pulse oximeter reading of 98%. On physical examination he was noted to be obese and to have bilateral wheezing. The patient was not in respiratory distress but in view of the two previous ER visits, the diagnosis of asthma and pneumonia and the mother's inability to provide appropriate treatment in the home the decision was made to admit the child to the hospital with a diagnosis of asthma exacerbation and a right upper lobe pneumonia, The plan was to treat with intravenous (IV) ceftriaxone, azithromycin, prednisone, and albuterol every 3 hours. 

The insurer has denied the admission as not medically necessary and indicated that there was no documentation in the medical record to support the need for inpatient treatment. 

The patient was treated appropriately in the ER for an acute episode of wheezing, difficulty breathing and pneumonia. The patient has a history of a previous hospitalization for asthma when he was 3 years of age. When the mother did not obtain the medication to treat pneumonia and asthma, which had been prescribed following the ER visit 4 days prior to the admission, she returned immediately following an ER visit on the same day of the admission. It was determined that the mother was not competent to treat the child on an outpatient basis. 

Based on the mother's inability to care for this child's asthma and pneumonia on an outpatient basis it was determined that he could not be discharged because of the risk to his health related to the following issues: -Poor adherence with outpatient medication regimen -Poor social support system at home, with inability of the caregiver(s) to provide medical care and supervision at home (Up to Date). 

The decision to admit to the hospital for treatment of pneumonia and asthma exacerbation was appropriate and consistent with the standard of care. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.