Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rhinovirus/enterovirus, asthma attack
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a toddler-aged male child born prematurely with medical history significant for mild persistent asthma. He was taken to the ED (emergency department) with three-day history of worsening cough and congestion, treated unsuccessfully with albuterol. He had no fevers. Historically he had been hospitalized four times, twice in the PICU (pediatric intensive care unit) with no intubations. The patient's vital signs included temperature 98.1, heart rate 145, respiratory rate 20, and 95% (percent) saturation in room air. Examination was significant for moist mucous membranes, accessory muscle use, wheezing, awake and alert. Laboratory testing was significant for positive enterovirus/rhinovirus. CBC (complete blood count) was unremarkable. The patient was treated with dexamethasone, three nebulized saline treatments, and three nebulized albuterol treatments per the patient's mother's request, with some improvement in retractions. He was subsequently admitted for ongoing management. Admission orders included IV (intravenous) fluids at half-maintenance, regular diet as tolerated, supplemental oxygen as needed to maintain saturations greater than 92%, albuterol every two hours and as needed, Atrovent every six hours as needed, dexamethasone daily, asthma action plan, and asthma education. Chest x-ray was unremarkable. An Infectious Disease consultation was obtained, in agreement with his treatment plan. He slept well overnight, was taking adequate fluids well, remained afebrile, and per father was at baseline. Treatments were spaced to every three hours, IV fluids were discontinued to encourage oral intake, and he completed a four-dose course of Atrovent. The patient was significantly clinically improved by day # (number) 2, with some cough but no respiratory distress. His appetite had improved, he remained afebrile, and he was tolerating spaced albuterol treatments. He was deemed stable for discharge to complete a five-day course of steroids.

The inpatient hospital 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, as a result of atelectasis and airway over-distention. There are many possible triggers including exposure to allergens and upper respiratory viral infections. Unfortunately, asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough. 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 child born prematurely with strong family history of asthma and personal history of asthma with multiple hospitalizations presented to the ED after having failed treatment at home. Testing revealed infection with enterovirus/ rhinovirus. He was treated aggressively in the ED with systemic steroids, nebulized saline, and nebulized albuterol, without sufficient improvement. While it was reasonable to monitor him in the hospital while continuing frequent albuterol treatments, he was overall hemodynamically stable with no evidence of impending respiratory failure, no significant dehydration, and no need for supplemental oxygen. He did not require acute inpatient hospital admission and he could have been safely managed at a lower level of care.