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 mild persistent asthma, allergic rhino-conjunctivitis, multiple food allergies, chronic constipation, and gastroesophageal reflux disease.  He presented to the emergency department with three-day history of cough and congestion and one-day history of worsening shortness of breath. He had been seen in the emergency department two days prior for worsening shortness of breath and treated for asthma exacerbation before discharging home. He remained symptomatic despite albuterol every four hours. 

The patient was admitted to the pediatric intensive care unit (PICU) for asthma previously and most recently admitted for exacerbation about one year prior to this admission. Vital signs in the emergency department included temperature 36.5, heart rate 120, respiratory rate 18 with 97% saturation, and blood pressure 112/68. Examination was significant for moist oral mucosa, enlarged tonsils, moderate expiratory wheezing, moderate cough, mild decreased air entry, and non-focal neurologic exam. Laboratory evaluation revealed negative rapid influenza and respiratory syncytial virus. Chest x-ray was unremarkable with no focal airspace disease or consolidation. He was treated with albuterol, three DuoNebs, magnesium, and dexamethasone, but continued to have wheezing. Admission orders included albuterol every three hours, enteral corticosteroids, famotidine for gut protection, half-maintenance intravenous (IV) fluids, regular diet, and asthma education. The patient was able to tolerate albuterol every four hours, could speak in full sentences, and had no respiratory distress. He was deemed stable for discharge home, to follow-up with Pulmonology in one week.

No, acute 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, as a result of atelectasis and airway over-distention. Status asthmaticus is defined as "severe asthma that fails to respond to inhaled beta-agonists, oral or intravenous steroids, and requires admission to the hospital for treatment." (1) Asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough. "Despite advances in asthma management, acute exacerbations continue to be a major problem in patients our review findings support the importance of controlling persistent asthma early episodic intervention appeared to be crucial in preventing severe attacks and future exacerbations." (2)

In the 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 emergency department, admission is necessary.

This patient, with mild persistent asthma, presented to the emergency department for the second time with worsening shortness of breath despite albuterol every four hours. He was aggressively treated in the emergency department, but he continued to have scattered wheezing so was admitted for further management. While it was reasonable to continue aggressive bronchodilator treatment in the hospital, monitoring his response to therapy, he was overall hemodynamically stable with no evidence of impending respiratory failure. He did not require acute inpatient admission and could have been safely managed at a lower level of care like observation.