Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is overturned. 

The patient is a male who was brought to the emergency department with coughing, wheezing, and respiratory distress. 
He was well until 2 days prior to presentation when he developed a cough. The day prior to presentation he had difficulty sleeping and kept waking up and crying. The next morning, he awoke with a cough and a runny nose. He was noted to be wheezing and having respiratory distress at that time. He also had episode of post-tussive emesis. He was given an albuterol inhaler treatment at home but had no improvement, so he was brought to the emergency department for evaluation. 
His past history was significant for 1 previous hospitalization for an asthma exacerbation. He also had seasonal allergies. 
In the emergency department his temperature was 100.4 Fahrenheit (F), pulse 164, and respiratory rate 24. On examination he was found to have tachypnea, nasal flaring, and retractions with wheezing. He received albuterol/Atrovent nebulized treatments as well as corticosteroids. He continued to wheeze after these treatments, and therefore magnesium was also administered. He improved somewhat after that treatment but remained tachypneic and had abdominal breathing. He was therefore admitted to the hospital for further management. 
In the hospital he was initially given albuterol treatments every 3 hours as well as prednisone. He improved during his stay and was able to space to every 4 hour treatments prior to discharge. On the second day he was felt to be stable for discharge to home, with continued bronchodilator treatment, initiation of Flovent, and follow up in 1-2 weeks as an outpatient. 
The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is overturned. 

The requested health service of inpatient hospitalization was medically necessary for this patient. 
He required continued treatment with frequent bronchodilator therapies, along with close monitoring with additional treatments as needed. Children with status asthmaticus who require bronchodilator therapies more frequently than every 4 hours require inpatient treatment and monitoring. This patient had continued respiratory distress after appropriate treatments, and initially required every 3 hour bronchodilator therapy in the hospital. 
This patient presented in status asthmaticus. He was in respiratory distress at the time of his presentation with tachypnea, nasal flaring, and retractions. He had received appropriate treatment with albuterol at home but continued to be symptomatic. He then received intensive and appropriate treatment in the emergency department, with albuterol/Atrovent treatments, corticosteroids, and magnesium. However, he continued to have tachypnea as well as abdominal breathing despite this treatment. He required continued treatment with frequent bronchodilator therapies, along with close monitoring with additional treatments as needed. Children with status asthmaticus who require bronchodilator therapies more frequently than every 4 hours require inpatient treatment and monitoring. This patient had continued respiratory distress after appropriate treatments, and initially required every 3 hour bronchodilator therapy in the hospital.
Patients with asthma who are moderately to severely ill on arrival and who have little improvement therapy with beta-agonists and systemic glucocorticoids require hospitalization. This includes patients who continue to have wheezing and increased work of breathing. 
The decision-making at the time of admission for this patient was consistent with his young age, the presence of status asthmaticus with symptoms that continued despite appropriate and intensive treatments, and the need for continued frequent bronchodilator treatments along with close monitoring for potential deterioration of clinical status.