Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Persistent Asthma with Acute Exacerbation
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is overturned.

The patient is a female with severe persistent asthma who presented with an asthma exacerbation. She was well until the morning of presentation when she began coughing excessively with audible wheezing. She had shortness of breath and was unable to speak in full sentences. She had been having increased asthma episodes over the prior 2 months and was using Albuterol as well as her controller medication. She also had recently taken 2 rounds of corticosteroids and was treated with antibiotics for acute bronchitis. She has a history of severe persistent asthma with an elevated Immunoglobulin E (IgE) to 2,500.
In the emergency department, she was treated with 3 Albuterol/Atrovent nebulized treatments, Dexamethasone, and Magnesium. Laboratory values were obtained as well as a chest x-ray. The chest x-ray revealed bilateral perihilar cuffing. Upon re-evaluation she continued to have wheezing and shortness of breath. She was subsequently admitted to the hospital for further treatment of an acute asthma exacerbation with acute bronchitis.
Upon admission she continued to have wheezing in all lung fields. She was treated with Albuterol every 2 hours, Ipratropium every 4 hours, Solumedrol, Symbicort, and Spiriva. She was also treated with oral Augmentin for bronchitis. She continued to wheeze and the pulmonology team was consulted. She then improved over time and was able to wean to every 3 hour and then every 4 hour Albuterol treatments.She was doing well and was felt to be stable for discharge to home with follow-up as an outpatient.

The requested health service/treatment of Inpatient Hospital Admission was medically necessary for this patient. Patients with asthma exacerbations require hospitalization if they continue to have significant symptoms despite appropriate therapies and if they require bronchodilator treatments more often than every 4 hours. This patient initially required every 2 hour treatments as well as parenteral Solumedrol and continued to have significant wheezing. Therefore, hospitalization was necessary.
This is a patient with severe asthma who presented with an acute asthma exacerbation. She received appropriate and intensive treatments in the emergency department setting, but she continued to have significant wheezing and shortness of breath. She therefore required inpatient admission for ongoing treatment with frequent bronchodilator treatments (initially every 2 hours), corticosteroids, and specialist consultation along with close monitoring and additional treatments as needed.
The decision making at the time of admission for this patient was consistent with her young age, the presence of continued wheezing and shortness of breath despite appropriate and intensive therapies, and the need for ongoing frequent treatments along with close monitoring for potential deterioration of clinical status.
The MCG Health Croup Guidelines included do not apply to this patient who presented with an asthma exacerbation. However, she met criteria for hospital admission based on her continued significant symptoms despite appropriate therapy and the need for ongoing, frequent treatments with monitoring.