Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System-Cough. 
Treatment: Inpatient Hospital. 

The insurer denied Inpatient Admission. 
The denial is upheld in whole. 

The patient is a female who presented at night with a history of cough, runny nose and fever with temperature maximum of 101. She was seen at her primary care physician (or provider) (PCP) the day before admission, and was given albuterol nebulizer, which the patient drank by mouth on accident. 
In the emergency department (ED), she was noted to be febrile to 102.6, heart rate of 183, respiratory rate was 58, and she was 94% on room air. The physical exam showed moderate distress with diffuse wheezing and poor air movement bilaterally. Noted was some tracheal tugging and abdominal retractions. She was given Decadron by mouth (PO), duo nebulizer times (X) 3 and Motrin. Her fever resolved, but she was noted to have minimal change in respiratory exam and was given magnesium intravenous (IV) bolus, and one-hour continuous albuterol nebulizer. She improved and was able to be spaced to every 2 hours. At 2 hours, retractions, tachypnea, and prolonged expiration were noted. A chest x-ray was done and noted to have concerns for right middle lobe consolidation, however the read was unremarkable. Amoxicillin was given. Labs showed a potassium (K) at 3.2, and bicarbonate (HCO3) was 22. She was started on maintenance intravenous fluids and admitted. The respiratory viral panel (RVP) was negative. 

On the pediatric floor, the patient was stable, with no signs of respiratory distress. Rales were heard over the right lower lobe. Ampicillin was ordered for every 6 hours. The patient had a temperature of 101.8 and received Tylenol. She was spaced to every 4 hours of albuterol without difficulty and deemed stable for discharge. She was sent home with Amoxicillin for 6 more days, and PCP follow up in 1-2 days. 
At issue is the medical necessity of the Inpatient Admission. 

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

The requested health service/treatment of Inpatient Admission is not medically necessary for this patient. 

According to the National Institute of Health (NIH) Asthma guidelines, patients that appear moderately to severely ill on arrival and who have little improvement or worsen after initial therapy with beta-agonists and systemic glucocorticoids require hospitalization. This includes patients who continue to have significant wheezing and retracting and poor aeration after following NIH guidelines. The NIH guidelines recommend to give a patient up to 3 doses in the first hour of short acting beta agonist (SABA) as well as corticosteroids. If there is no improvement continue treatment for 1-3 hours. If there is no distress and the response is sustained 60 minutes after last treatment the patient can be sent to home. However, if there is incomplete response or mild to moderate symptoms an individualized decision can be made towards admission. The NIH recommends physical exam findings such as the use of accessory muscles, inspiratory and expiratory wheezing, paradoxical breathing, cyanosis, and a respiratory rate greater than (>) 60 are key signs of serious distress. 
This member received the 3 SABA upon arrival as well as corticosteroids. A mild response was noted, and an IV magnesium bolus was given. Upon admission to the inpatient floor there was no indication by provider notes or nurses notes that the patient had any wheezing, tachypnea, retractions, decreased aeration, respiratory distress, and Pediatric Early Warning System (PEWS) scores remained 0-1. She was quickly spaced from every 2 hours to every 3 and then 4 hours without any changes. As per the NIH guidelines, a patient can be safely discharged home who has marked improvement in clinical parameters. 
Therefore, the requested health service/treatment of Inpatient Admission is not medically necessary.