Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma exacerbation and worsening nephrotic syndrome.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male child with medical history significant for nephrotic syndrome steroid-dependent, as well as asthma. He was referred to the ED (emergency department) by his nephrologist for evaluation of asthma exacerbation and worsening nephrotic syndrome with proteinuria. He had one-week history of cough and fever, decreased intake, and decreased activity. He had not voided since the day prior. He had been seen by his pediatrician two days prior and diagnosed with otitis media, started on cefdinir, and the family was told he had significant proteinuria.

The patient's vital signs included temperature 97.1, heart rate 109, respiratory rate 24, and blood pressure 103/65. Examination was significant for no distress, bilateral erythematous ear canals tender when tugging on pinna, no nasal discharge, moist oral mucosa, scattered wheezing on left, barking cough, benign abdomen, 1+ [plus] pitting edema bilateral lower extremities, and non-focal neurologic exam. On attending examination, the child also manifest decreased aeration, bilateral crackles, and retractions. Laboratory evaluation revealed concentrated urine with specific gravity 1.031 and greater than 1000 protein, respiratory panel positive for both RSV (respiratory syncytial virus) and enterovirus/rhinovirus, normal WBC (white blood count) count 11.5K (thousand) with 81% [percent] neutrophils, thrombocytosis with platelets 555K (thousand), venous blood gas with pCO2 (partial pressure of carbon dioxide) elevated at 53, mild hyperkalemia with potassium 5.6, and mild hypoalbuminemia 3.3. Chest x-ray was unremarkable.

The patient was treated with three back to back nebulized albuterol treatments every twenty minutes, a dose of dexamethasone, 10mg (milligrams) continuous albuterol, parenteral magnesium, and then albuterol every two hours. He was place on supplemental oxygen due to ongoing respiratory distress. He was ultimately admitted due to ongoing acute bronchospasm in the setting of nephrotic syndrome flare while on enteral steroids. Admission orders included albuterol every two hours, supplemental oxygen as needed, continued steroids as per nephrotic syndrome dosing, maintenance IV (intravenous) fluids until taking adequate oral diet, consideration for ceftriaxone instead of cefdinir for treatment of otitis media, and close monitoring of ins and outs.

The patient was able to tolerate transition to treatments every three hours, and then every four hours  He remained on his other treatments and was given ceftriaxone for his otitis media. He remained on the higher dose of steroids for relapsed nephrotic syndrome and IV (intravenous) fluids were slowly weaned. He had also been weaned to room air successfully. He continued to improve and was deemed stable for discharge to follow-up with pulmonology, nephrology, and his pediatrician.

Yes, the Inpatient admission was medically necessary and appropriate in this case.
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. Unfortunately, asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough.

In the ED (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 ED (emergency department), admission is necessary.

This young child presented to the ED (emergency department) with week-long URI (upper respiratory infection) symptoms, otitis media treated with an oral antibiotic, acute asthma exacerbation, and relapsed nephrotic syndrome despite ongoing treatment with enteral steroids. He was aggressively managed in the ED (emergency department) with frequent back to back albuterol followed by continuous albuterol followed by albuterol every two hours, magnesium, parenteral steroids, and supplemental oxygen. Lab studies substantiated his relapsed nephrotic syndrome with significant proteinuria and mild hypoalbuminemia. While he was hemodynamically stable with no evidence of impending respiratory failure, the combination of relapsing steroid-dependent nephrotic syndrome, status asthmaticus, and multiple viral infections (RSV [respiratory syncytial virus], enterovirus/rhinovirus) was serious enough to mandate acute inpatient admission. He could not have been safely managed at lower level of care. He required acute management of fluids and electrolytes, monitoring of blood pressure and urine output, monitoring for respiratory decompensation, and close monitoring of need for supplemental oxygen. This is most consistent with acute inpatient level of care.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.