Appeal type: Medical necessity
Decision: Overturned

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

The patient has a history of asthma and presented to the emergency department (ED) via Emergency Medical Services (EMS) with difficulty breathing at school. He had discomfort in his throat and chest and had a one-week history of productive cough with green sputum. He received two DuoNeb treatments prior to arrival. Vital signs included temperature 36.8, heart rate 140, respiratory rate 22, and blood pressure 114/53. He was treated with Orapred, DuoNeb's and continuous albuterol for two hours, normal saline bolus, and magnesium. Venous blood gas showed partial pressure of carbon dioxide elevated at 50.3, combined respiratory and metabolic acidosis, and normal white blood cell count with left shift (72% neutrophils). He continued to have diffuse wheezing. He was admitted to the Pediatric Intensive Care Unit with diagnosis of status asthmaticus. Admission orders included albuterol hourly, parenteral corticosteroids, and regular diet. He required supplemental oxygen. He was started on ceftriaxone for possible pneumonia, with chest x-ray revealing atelectasis with possible superimposed infection.

Pneumonia occurs because of inflammation of lung tissue from either infectious or non-infectious causes. Infectious causes include bacteria, viruses, and fungi. Non-infectious causes include aspiration, hypersensitivity reactions, and drug or radiation-induced pneumonitis. Pneumonia is typically preceded by upper respiratory tract infection symptoms, including cough and runny nose. Tachypnea, fever, cough, and chest pain may be present. Physical findings include decreased breath sounds, crackles, tachypnea, and shortness of breath. Infiltrate on chest x-ray is supportive of the diagnosis and may be accompanied by effusion. There may be laboratory indicators of infection, including leukocytosis and elevated inflammatory markers. Hospitalization may be warranted in the very young, patients with concurrent serious chronic medical conditions, moderate to severe respiratory distress, need for supplemental oxygen, dehydration, inadequate response to outpatient therapy, and complications.
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 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 patient was taken to the ED  because of increased work of breathing. He had cough productive of purulent sputum for a week prior to this asthma exacerbation with positive ill contact at home. He was treated with bronchodilators prior to arriving at the hospital, and he was aggressively treated in the ED. Despite this management, he continued to manifest difficulty breathing and signs and symptoms of bronchospasm. Subsequent chest x-ray revealed possible infectious infiltrate, substantiated by need for supplemental oxygen. He failed appropriate and aggressive outpatient management. He required acute inpatient admission and could not be safely treated at a lower level of care without risk of morbidity. The acute inpatient admission and full duration of his hospital stay were medically necessary and appropriate.