Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath
Treatment: Inpatient Stay
The insurer denied: Inpatient Stay
The denial is: Upheld.

The patient is a male with medical history significant for heart murmur that presented to the emergency department (ED) with three-day history of fever, cough, and increasing shortness of breath. He also reported dyspnea on exertion and substernal chest tightness. He had one episode of vomiting, but no diarrhea. He had no history of asthma and had received two doses of coronavirus 2019 (COVID-19) vaccine.

Vital signs included temperature 38.9 Celsius, heart rate 138, respiratory rate 28. Examination was significant for diaphoresis, tachypnea, able to speak in full sentences, tachycardia, decreased bilateral breath sounds, faint expiratory wheezes, and non-focal neurologic exam. Treatment included anti-pyretic medications, chest x-ray, three DuoNebs, intravenous (IV) fluid bolus, viral respiratory panel, and blood work. Lab studies were significant for negative screening for influenza, respiratory syncytial virus (RSV), and Covid19. Additional significant labs included white blood cell (WBC) count of 16.0 thousand (K) with left shift 76% neutrophils, sodium 133, troponin 0.0. Chest x-ray revealed only mild pectus excavatum with no infiltrate. Electrocardiogram revealed only sinus tachycardia. He was placed on continuous albuterol, treated with magnesium and ceftriaxone, and admitted to the Pediatric Intensive Care Unit (PICU) for further management of status asthmaticus with acute respiratory failure and possible pneumonia. Admission orders included albuterol every hour weaning as tolerated, Atrovent every six hours, methylprednisolone every six hours, daily ceftriaxone, and regular diet.
While in the PICU, he was successfully weaned to albuterol every two hours, with no need for supplemental oxygen, better air entry, and no increased work of breathing. He was transferred to the floor for ongoing management. Transfer orders included continuous pulse oximetry, famotidine, albuterol, Atrovent, methylprednisolone, and flu vaccine. Additional information was noted, with bicuspid aortic valve and mild aortic insufficiency. He was tolerating albuterol every four hours, stable in room air, and eating well. He was deemed stable for discharge to continue albuterol every four hours, prednisolone to complete five days, guaifenesin for cough, and follow-up with both primary care and pulmonology if needed.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The inpatient stay was not medically necessary for this patient.
Asthma is an inflammatory process characterized by airway obstruction due to airway hyper-responsiveness, bronchospasm, airway inflammation, and mucus production. 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.

While it was reasonable and appropriate to monitor this patient in the hospital to provide ongoing care, he was overall hemodynamically stable with no need for supplemental oxygen and no evidence of impending respiratory failure. He did not require acute inpatient admission and could have been safely managed at lower level of care.