Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath, cough, fever.
Treatment: Acute inpatient hospital admission.
The insurer denied the acute inpatient hospital admission.
The denial is upheld.

The patient is a female toddler with a medical history significant for premature birth and eczema who presented to the Emergency Department with a one-day history of mild shortness of breath, worsening cough, fever, wheezing, and cold symptoms. The cough was described as dry and intermittent. There was one episode of fever of 101 Fahrenheit. Wheezing was intermittent.
She was reported to be eating and drinking less at home. Vital signs included the
following: temperature 98.6 Fahrenheit, heart rate 147, respiratory rate 28 with 91% saturation on room air, and blood pressure 105/76 mmHg (millimeters of mercury). The examination was significant for non-toxic appearance, acute distress with accessory muscle usage and tachypnea, moist mucous membranes, diffuse wheezing, and non-focal neurologic exam.

The patient was treated with intramuscular dexamethasone and three DuoNeb
treatments. Repeat respiratory rate was 30 with 95-96% oxygen saturation on room
air. She had an episode of vomiting approximately thirty minutes after attempted
oral administration of dexamethasone and administration of intramuscular
dexamethasone. She remained tachypneic with bilateral wheezing and tachycardia.
At that time, lab studies and chest x-ray were ordered, and she was treated with a
normal saline bolus and magnesium. Rapid influenza and COVID testing were
negative. The metabolic panel was significant for mildly elevated aspartate
aminotransferase (AST) (49) and mild hyperglycemia (128), with elevated lactate
(3.3). She remained tachypneic and tachycardic, with adequate oxygen saturation
on room air and improved air entry, persistent wheezing, and occasional crackles.
At this time, the decision was made to admit her to the hospital for further care.
Chest x-ray was reported to be normal. Admission orders included maintenance
intravenous (IV) fluids, albuterol every three hours, enteral steroids twice daily, and
a review of cardiology records. The patient did well overnight and was stable on
room air, with no episodes of wheezing. She was able to wean albuterol with no
distress. She was deemed stable for discharge home to follow-up
with her pediatrician and pulmonologist.

No, the acute inpatient hospital admission was not medically necessary.

The patient was given a history of asthma and was treated as an asthmatic with
steroids and albuterol.

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 a medical history significant for prematurity and eczema
presented to the Emergency Department with an upper respiratory infection (URI)
symptoms and wheezing suggestive of reactive airway disease. She continued to
demonstrate wheezing and tachypnea despite treatment with bronchodilators,
corticosteroids, fluids, and magnesium, so she was admitted for further care.
However, the patient was hemodynamically stable with no significant hypoxia,
no need for supplemental oxygen, no severe distress requiring ventilatory support,
and no significant dehydration. As such, the patient did not require acute inpatient
admission. Acute inpatient hospital admission level of care was not medically necessary. The patient could have been successfully managed at a lower level of care.