Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male child with medical history significant for severe seasonal allergies, asthma, eczema, and possible immunodeficiency. He presented to the ED (emergency department) with two-day history of increasing difficulty breathing and one-day history of nausea and facial rash.

The patient's vital signs included temperature 36.6, heart rate 178, respiratory rate 40, and 88 => 93% saturation in room air. In triage, he was noted to be tachypneic with coughing, labored breathing, and diffuse wheezing, as well as faces score 6/10. He was gagging and grunting and had facial rash.

The patient was immediately placed on a monitor and given an IM (intramuscular) dose of epinephrine as well as methylprednisolone, Benadryl, and three CombiNebs to treat for possible anaphylaxis. Examination was significant for respiratory distress, moist mucous membranes, no peripheral edema, benign abdomen, normal speech, blanching rash over his face, and non-focal neurologic exam. He was subsequently also given continuous albuterol for an hour, as well as magnesium.

The patient's laboratory evaluation was significant for mild hypokalemia (potassium 3.3), mild metabolic acidosis (CO2 [carbon dioxide] 21), elevated pCO2 (partial pressure of carbon dioxide) (venous 52.9), and WBC (white blood cell) count 12.6K (thousand). Respiratory viral panel was negative. Chest x-ray was unremarkable.

The patient spiked a fever to 105.8 treated with Motrin (spat up) followed by Tylenol suppository. The albuterol was spaced out to every three hours, but because of ongoing increased work of breathing and wheezing he was admitted to the pediatric floor for further management. Admission orders included albuterol every three hours weaning as tolerated, Benadryl as needed for allergic symptoms, outpatient Allergy referral, follow-up blood culture, and regular diet.

The following day, the patient was placed on a five-day course of steroids. He was referred to Pulmonary, and was transitioned to treatments every four hours. However, he returned to treatments every three hours during the day and then back again to every four hours overnight. He continued to manifest some wheezing but had good air entry, was drinking well, was making good wet diapers, and was afebrile.

The patient was deemed stable for discharge home to follow-up with his pediatrician in two to three days, with referrals to Pulmonary and Allergy, to complete a course of steroids and continue using albuterol every four hours.

No, the Inpatient admission was not medically necessary. This child could have been safely managed at lower 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. 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 young child with history of poorly controlled atopic disease presented to the ED (emergency department) with signs and symptoms concerning either for allergic reaction or acute asthma exacerbation. He was treated for both in the ED (emergency department) and subsequently admitted because of persistent wheezing. Over the course of his hospital stay, he remained hemodynamically stable with no evidence of impending acute respiratory failure, no need for supplemental oxygen, and no significant dehydration. While it was reasonable and appropriate to manage his asthma exacerbation in a hospital setting, he did not require acute inpatient management. He could have been safely and appropriately managed at a lower level of care, such as observation.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.