Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Respiratory System/Asthma.
Treatment:  Inpatient Admission.

The insurer denied the inpatient admission.  The denial is overturned.

The patient is a boy with asthma who presented to the emergency department with status asthmaticus.  

He was well until the day of presentation when he awoke with shortness of breath. He used his Albuterol inhaler at home but had no relief. He had recently been using Albuterol more frequently and had used it before and after football practice. He also had some symptoms of rhinorrhea, nasal congestion, and throat pain the day prior to presentation, which had resolved.

The patient was initially seen at an outside emergency department and then transferred for further care. His past history is significant for a prior hospitalization for asthma.
Upon presentation in the emergency department, his temperature was 101 degrees Fahrenheit, and his heart rate was 116 beats per minute (bpm). His oxygen saturation was 92% on room air and he had diffuse wheezing on examination. Laboratory values were obtained, as well as a chest x-ray. He received 2 Albuterol treatments, as well as Ipratropium Bromide, Dexamethasone, and Magnesium Sulfate. He also received a bolus of normal saline. Upon reassessment, he did not feel he had improved, he continued to have diffuse wheezes bilaterally, and his oxygen saturation ranged from 92-95%. He was therefore admitted to the hospital for status asthmaticus.

In the hospital, he was treated with Albuterol every 3 hours, continued Dexamethasone, and supplemental oxygen as needed. The following day, he was given a second dose of Dexamethasone. He had continued on every 3-hour Albuterol treatments, and then was transitioned to every 4 hour treatments. He was tolerating oral intake and was felt to be stable for discharge to home, with follow up as an outpatient.

The inpatient admission is under review for medical necessity.

I overturn, in whole, the health plan's determination of medical necessity.

Yes, the requested health service/treatment of inpatient admission was medically necessary for this patient.
 
This is a boy, who presented with an acute onset of status asthmaticus. He had shortness of breath and diffuse wheezing upon presentation, as well as hypoxemia, and continued to have significant wheezing despite appropriate and intensive treatment in the emergency department including bronchodilators, corticosteroids, and Magnesium Sulfate. He was diagnosed with status asthmaticus and was admitted to the hospital for continued frequent bronchodilator treatments (initially every 3 hours) as well as continued corticosteroids, oxygen as needed, and close monitoring.

The decision making at the time of admission for this patient was consistent with his young age, the presence of status asthmaticus with continued significant wheezing despite appropriate and intensive treatments at home and in the emergency department, and the need for continued frequent bronchodilator therapy, corticosteroids, and close monitoring for potential deterioration of his clinical status.

Patients with asthma, who are moderately to severely ill on arrival and who have little improvement after initial therapy with beta-agonists and systemic glucocorticoids, require hospitalization. This includes patients who continue to have significant wheezing and require beta-agonist therapy more often than four hours. This patient continued to have significant wheezing after appropriate treatment, and he required beta-agonist therapy every 3 hours along with close monitoring. He, therefore, required an inpatient admission.