Appeal type: Medical necessity
Decision: Upheld

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 upheld.

The patient is a male child with an allergy to peanuts and tree nuts that presented to the emergency department (ED) with a two-day history of shortness of breath, rapid shallow breathing, and wheezing that started after playing football and recurred when he was playing hockey. He had been hospitalized two weeks prior with pneumonia. An examination was significant for clear breath sounds with symmetric chest movement, benign abdomen, and non-focal neurologic exam. Vital signs included temperature of 100.1F (Fahrenheit)., and an oxygen saturation of 96% in room air. He was treated with hand-held nebulized bronchodilators, corticosteroids, and magnesium. A chest x-ray was unremarkable. Because of the persistent wheezing, an intravenous (IV) was placed to start IV fluids and draw labs. He was placed on a cardiorespiratory monitor (heart rate 126 beats per minute (bpm)) in observation. He continued to have wheezing in all lung fields but was able to eat dinner. The patient was subsequently admitted for further management. He did well overnight with breathing treatments every three hours. The patient was eating well, able to speak in full sentences, with no supplemental oxygen requirement. He was transitioned from nebulized bronchodilators to bronchodilators via inhaler. The patient did well and was deemed stable for discharge to complete his course of corticosteroids and follow-up with pulmonology.
At issue is the medical necessity for the inpatient stay.

The health plan's determination of medical necessity is upheld, in whole.

No. The patient could have been safely managed at an alternate level of care.
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. Status asthmaticus is diagnosed as a severe asthma exacerbation that fails to respond to inhaled beta-agonists and corticosteroids and requires close monitoring for resolution or progression. Unfortunately, asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough. Even though there have been significant advances in asthma management, acute exacerbations continue to cause significant morbidity in patients. Early intervention is essential to prevent severe attacks and future exacerbations.
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 male child had no history of asthma or reactive airway disease, but presented to the ED with wheezing, shortness of breath, and moist cough. He was treated with frequent bronchodilators, corticosteroids, magnesium, and fluids. While it was reasonable to monitor this child in the hospital because of persistent wheezing, he had no oxygen requirement, with no evidence of impending respiratory failure. He did not require an acute inpatient admission and could have been safely and appropriately managed at an alternate level of care.