Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is a toddler aged male child with medical history significant for asthma that presented to the emergency department with two-day history of rhinorrhea, nasal congestion, cough with post-tussive emesis, and increasing work of breathing. Treatments at home with nebulized albuterol were ineffective. The patient's vital signs included temperature 36.2, heart rate 162, respiratory rate 40, and saturation 89-92% in room air. Examination was significant for retractions and mild respiratory distress. He was treated with two DuoNebs and dexamethasone. Saturations continued to hover around 90%(percent) so he was given a third DuoNeb. Wheezing resolved but the patient continued to display retractions. He was given continuous albuterol with persistent suprasternal retractions. He was given magnesium and lab studies were obtained. Significant labs included hyperglycemia with glucose 241, hypokalemia with potassium 3.3, mild metabolic acidosis with carbon dioxide (CO2) 20, and leukocytosis with white blood cells (WBCs) 15.5 thousand and left shift 94.3% neutrophils. COVID and influenza were negative.

The patient was admitted for further management. Admission orders included continuous cardiopulmonary monitoring, age-appropriate diet, intravenous fluids at half maintenance, albuterol every three hours, and daily enteral steroids. The patient was not able to tolerate enteral steroids, so he was transitioned to parenteral steroids on day two. He was able to wean to albuterol every four hours by day three. He was breathing easily and was comfortable in room air. He was deemed stable for discharge on day number two.

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 from atelectasis and airway over-distention. There are many possible triggers including exposure to allergens and upper respiratory viral infections. Asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough. 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 young child with history of wheezing, subsequently diagnosed with asthma, presented to the emergency department with increased work of breathing unresponsive to bronchodilator treatments at home. He was treated with DuoNebs and continuous albuterol in the emergency department along with steroids and magnesium but remained symptomatic with accessory muscle use. While it was not inappropriate to continue to monitor the patient in the hospital, he was overall hemodynamically stable with no evidence of impending respiratory failure, no supplemental oxygen requirement, and no significant dehydration. He did not require acute inpatient admission and could have been safely managed at lower level of care.