Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Increased difficulty breathing
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male child with medical history significant for intermittent asthma (with no previous admissions), autism, and speech delay. He presented to the emergency department (ED) via emergency medical services (EMS) with increasing difficulty breathing. He had three-day history of runny nose and cough, treated with nebulized albuterol at home with minimal improvement. He had no fevers or GI (gastrointestinal) complaints. 

The patient's vital signs included temperature 100.4, heart rate 152, respiratory rate 39 with 95% saturation on room air, and blood pressure 108/65. Examination was significant for distress with mild subcostal retractions, nasal discharge, tachycardia, decreased air movement bilaterally with scattered wheezing, and non-focal neurologic exam. Laboratory evaluation revealed leukocytosis with WBC (white blood count) 16.3K, left shift with 75.4% neutrophils, mild thrombocytosis (platelets 393K), mild hyperglycemia (glucose 128), and mild metabolic acidosis on venous blood gas with pH 7.30 and bicarbonate 21.7 (CO2 [carbon dioxide] 23 on metabolic panel). He was treated with three rounds of DuoNeb, two treatments with nebulized albuterol, parenteral magnesium, enteral prednisolone, and a normal saline bolus. 

The patient was diagnosed with acute asthma exacerbation and admitted to the general pediatric floor for further management (he reportedly had partial improvement in the ED). Admission orders included IV fluids at half maintenance, regular diet for age, albuterol every three hours, nebulized saline every six hours as needed for nasal congestion, Tylenol/Motrin as needed for fever, and enteral prednisolone. Following admission, his asthma was recategorized as mild persistent asthma based on his nightly symptoms. 

The patient had no further fevers, and was able to wean treatments to every four hours. He was subsequently deemed stable for discharge home to complete his course of enteral steroids. 

No, the 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, 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)
 
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 presented to the ED with increased work of breathing, minimally responsive to nebulized bronchodilator treatments at home. He had low-grade fever, tachypnea, and mild subcostal retractions but no oxygen requirement. He experienced partial improvement in the ED, but remained sufficiently symptomatic that inpatient admission was deemed appropriate. While it was not unreasonable to monitor him for a longer period of time in the hospital, he was overall hemodynamically stable without significant dehydration and without signs or symptoms of impending respiratory failure. He did not require acute inpatient admission, and he could have been safely managed at a lower level of care.