Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


The patient has a medical history significant for eczema and reactive airway disease and presented to the emergency department (ED) with a one-day history of a cough and wheezing, with rapid breathing and poor oral intake. Vital signs included a temperature of 98 degrees Fahrenheit, heart rate 152, and respiratory rate 50. A respiratory viral panel was obtained and ultimately negative. A chest x-ray was unremarkable. He was treated with Decadron, two DuoNebs, and Albuterol. He was able to drink some juice and eat a bit while in the ED. He continued to exhibit tachypnea and wheezing so was admitted for further management. Admission orders included intravenous (IV) fluids, albuterol every two hours weaning as tolerated, regular diet for age, enteral steroids, and Vaseline as needed for eczema. Overnight he continued to have increased work of breathing and wheezing. An asthma action plan was developed and recommendations included an outpatient pulmonary evaluation. He was able to slowly wean the albuterol treatments to every four hours, and  was eating at baseline, with no oxygen requirement, tolerating treatments every four hours.
At issue is the medical necessity of an inpatient stay.

No, an inpatient stay 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 ED, 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, admission is necessary.
This young male with a history of atopic disease (eczema, wheezing) presented to the ED with worsening cough and wheezing. Despite appropriate treatment in the ED with steroids and bronchodilators, he remained symptomatic prompting hospitalization. While he required treatment beyond what could be provided at home, he was overall hemodynamically stable with no oxygen requirement and 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.