Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System/Asthma.
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is overturned.

The patient is a boy who presented with status asthmaticus.
He was well until 2 days prior to admission when he developed a cough, and his temperature went up to 100F. at home. He was kept home from school and was given Albuterol treatments before going to an urgent care center for evaluation due to worsening of his symptoms. In the urgent care center, he was given another dose of Albuterol and was transferred to the emergency department for further care for respiratory distress.
His past history is significant for mild intermittent asthma, with no recent symptoms. He was hospitalized for asthma once previously.
In the emergency department the patient was found to have a temperature of 99.5F., a respiratory rate of 28/minute, and an oxygen saturation of 93%. On physical examination he was described as being in acute distress and had decreased air movement with a prolonged expiratory phase and intercostal and subcostal retractions. He was given 3 Albuterol/Atrovent nebulized treatments as well as Methylprednisolone. After these treatments he had some improved aeration but continued to have tachypnea and increased work of breathing. He was then given a bolus of Magnesium Sulfate as well as a bolus of normal saline. He was subsequently admitted to the hospital for the continued treatment of status asthmaticus.
In the hospital he was placed on the asthma pathway. He was initially treated with Albuterol every 2 hours and then weaned to every 3 hours. He was also given oral corticosteroids. His respiratory status improved and over time he was able to space to every 4-hour treatments. The patient also received asthma education along with his family. He was felt to be stable for discharge to home with continued treatment and follow-up as an outpatient.
The hospitalization is under review for medical necessity.

I overturn, in whole, the health plan's determination of medical necessity.

Yes, the requested health service/treatment of an inpatient stay was medically necessary for this patient. After initial intensive treatment in the emergency department, he continued to require frequent bronchodilator treatments for respiratory distress with monitoring. The required an inpatient setting and would not have been appropriate for a lower level of care.
This is a young boy who presented in status asthmaticus. He was experiencing an increased work of breathing at home and continued to worsen despite appropriate therapy. He was seen in urgent care and then transferred to the emergency department due to respiratory distress. In the emergency department he was found to have decreased air movement, retractions, and hypoxemia. He received intensive treatments but continued to have tachypnea and increased work of breathing. The patient therefore required continued treatment as an inpatient for frequent bronchodilator administration and cardiorespiratory monitoring, with additional treatments as needed.
The decision-making at the time of admission for this patient was consistent with his young age, the presence of respiratory distress that continued despite intensive and appropriate treatments, and the need for continued intensive therapies along with close monitoring for potential deterioration of clinical status.