Appeal type: Medical necessity
Decision: Upheld

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

The patient is a teenage male with medical history significant for intermittent asthma, eczema, multiple food allergies (shellfish, peanuts, dairy, eggs, fish), and bilateral glaucoma. He presented to the ED (emergency department) in the early morning with 
one-day history of difficulty breathing. He was using albuterol without sufficient benefit, and he was having difficulty talking.
The patient's vital signs included temperature 36.6, heart rate 85, respiratory rate 16, and 98% (percent) oxygen saturation in room air. Examination was significant for bilateral wheezing, tachypnea, 
regular heart rate and rhythm, benign abdomen, and good perfusion. He was treated with combo nebs, dexamethasone, magnesium, normal saline bolus. Viral panel was negative. He continued to report chest tightness, with inspiratory/expiratory wheezing. He was admitted for further management. The patient's admission orders included albuterol every two hours, regular diet, continued home glaucoma treatment, asthma action plan, EpiPen for home, and Project Breathe education. His blood 
pressure was elevated during his hospital stay, with plans to follow as an outpatient. He was treated with a second dose of dexamethasone prior to discharge. He was able to transition to treatments every four hours. An action plan was completed. He was deemed stable for discharge the next day to follow-up with his primary care practitioner in the following day.

The Inpatient admission was not medically necessary.

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 from atelectasis and airway over-distention. There are many possible triggers including exposure to allergens and upper respiratory viral infections. Unfortunately, asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough. In the ED (emergency department), 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 (emergency department), admission is necessary. This teenage male with atopic disease presented with signs and symptoms of acute asthma exacerbation. Respiratory viral panel testing was negative. He was treated aggressively in the ED (emergency department) with bronchodilators, fluids, magnesium, and steroids with ongoing symptoms. While it was reasonable to monitor him in the hospital for improvement with weaning therapy, he was overall hemodynamically stable with no need for supplemental oxygen, no need for ventilatory support, and no evidence of impending respiratory failure. He did not require acute inpatient management and could have been safely managed at lower level of care.