Appeal type: Medical necessity
Decision: Upheld

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

The patient is a pediatric female child with medical history significant for coarctation of the aorta status post surgical repair, atrial septal defect, and patent ductus arteriosus status post ligation. She presented to the ED (emergency department) with one day history of fever, cough, congestion, and rhinorrhea. She was treated with albuterol at home with some improvement. However, the symptoms worsened overnight with post-tussive emesis, so she was taken to the ED (emergency department) for evaluation. Of note, she had been seen by Cardiology a few days before becoming ill, with reportedly reassuring echocardiogram.
The patient's vital signs included temperature 39.4 (degrees Celsius), heart rate 166, respiratory rate 32 with oxygen saturation 94%. Examination was significant for respiratory distress including tachypnea, retractions, wheezing, and decreased air movement. Chest x-ray was concerning for pneumonia. Laboratory evaluation was essentially unremarkable. She was treated with three Combinebs, parenteral solumetrol, and azithromycin. She improved initially, but continued to have persistent increased work of breathing. The PICU (pediatric intensive care unit) was contacted, with recommendations to treat with IV (intravenous) fluids, Tylenol, and magnesium. She was transferred for further evaluation.
Upon admission, the patient was noted to be crying, with good aeration, no wheezing appreciated, belly breathing with suprasternal retractions, and no nasal flaring. Admission orders included albuterol every two hours with consideration for transitioning from nebulize to MDI (metered dose inhaler) with spacer once tolerating treatments every three hours, continued steroids for total five days, regular pediatric diet, asthma education.
The day before discharge, the patient was stable in room air, tolerating albuterol every four hours, but with constant coughing overnight. She had no fevers and was tolerating a regular diet. She was transitioned back to albuterol every three hours and monitored an additional night.
The patient was able to wean back to treatments every four hours and was deemed stable for discharge home.
The Inpatient Hospital 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, 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 female child with history of congenital heart disease repaired that presented to the ED (emergency department) with one day of worsening respiratory symptoms. She was treated aggressively in the ED (emergency department), but continued to have increased work of breathing. While it was not unreasonable to monitor her in the hospital for response to treatment, she was overall hemodynamically stable with no signs of impending respiratory failure or significant dehydration. She did not require acute inpatient admission and could have been safely managed at a lower level of care.
The health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.