Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is overturned.
The Inpatient admission was medically necessary.
The patient is a male child with medical history significant for gastroesophageal reflux, intermittent asthma, milk allergy, and autism. He presented to the ED with persistent cough. He had been seen previously in the ED and treated with three DuoNebs and steroids. The cough and shortness of breath continued despite treatments with albuterol every four hours, and he was eating less than usual. He had no fevers. 
The patient's vital signs included temperature 98.0, heart rate 126, respiratory rate 28 with 97% saturation in room air, and blood pressure 95/65. Examination was significant for mild distress due to cough, well hydrated, moist oral mucosa, tachypnea, suprasternal retractions with diffuse expiratory wheezes, and non-focal neurologic exam. Chest x-ray was unremarkable. Laboratory evaluation was significant for leukocytosis (WBC [white blood count] 15.6K), unremarkable metabolic panel, and negative rapid RSV (respiratory syncytial virus)/influenza testing. He was treated with three DuoNebs, Solumedrol, magnesium, Zofran, and a normal saline bolus. He remained symptomatic so was given continuous albuterol treatment. His symptoms improved with cessation of coughing and wheezing and normalized work of breathing. However, within an hour of stopping the continuous albuterol, he had return of symptoms of bronchospasm, prompting additional course of continuous albuterol. At this time arrangements were made for admission to the PICU (pediatric intensive care unit) for further management of status asthmaticus. 
The patient's admission orders included bronchodilators (albuterol ten puffs hourly, Atrovent every six hours), parenteral corticosteroids, regular diet, and continuation of home GI (gastrointestinal) prophylaxis. He tolerated spacing of the albuterol to every three hours overnight. He remained stable on room air and was able to tolerate enough by mouth to discontinue IV (intravenous) fluids. The parenteral steroids were transitioned to enteral steroids. Pulmonary consulted with recommendations to continue systemic steroids for five days, wean albuterol as tolerated, start Flovent in the outpatient setting and follow-up in three to four weeks in pulmonary clinic. He was deemed stable for discharge later that day. 

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) Unfortunately, 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)
 
.... For patients with moderate to severe exacerbations that do not respond to such intensive therapy in the ED, admission is necessary.

While this child was only in the PICU for a short while, he had failed both outpatient therapy and aggressive management with observation in the ED. The care that he received during his hospital stay was most consistent with acute inpatient management. Lower level of care was not appropriate in this case, consistent with current guidelines and standards of care.