Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is overturned.

The patient is a male with a history of asthma who presented to the emergency department with respiratory distress.
He was well until the night prior to presentation when he developed tightness in his chest as well as a runny nose and cough. He also had some emesis. The following day he was given 2 albuterol nebulized treatments but was still not improving. He was therefore brought to the emergency department for further care.
His past history is significant for asthma, with 5 prior hospitalizations including an admission to the intensive care unit.
In the emergency department he was found to have respiratory distress with an oxygen saturation of 95%. He received 3 albuterol/Atrovent nebulized treatments as well as Magnesium Sulfate, a fluid bolus, and prednisone. Laboratory values were obtained, and he was transferred for admission to the intensive care unit, for further management of status asthmaticus.
In the hospital he was initially tachycardic with a heart rate of 150 and a respiratory rate of 35. He received albuterol every 90 minutes, which was weaned to every 3 hours prior to transfer to the hospital floors. He was also continued on maintenance intravenous fluids. He required supplemental oxygen for oxygen saturations below 92%. His increased work of breathing continued, so he was transferred to the floors with supplemental oxygen. He was then able to wean to room air. By the next day he was felt to be stable for discharge to home with follow up 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 stay was medically necessary for this patient, due to the need for intensive treatments and close monitoring.
This is a patient who presented with status asthmaticus. He received appropriate and intensive treatment in the emergency department, but he continued to have respiratory distress. He required ongoing treatment with frequently bronchodilators (initially every 90 minutes), intravenous fluids, and careful monitoring. He also required supplemental oxygen.
The decision making at the time of admission for this patient was consistent with his young age, the presence of status asthmatic and respiratory distress, a history of multiple prior hospitalizations including to the intensive care unit, and the need for ongoing intensive treatment in an inpatient setting along with close monitoring for potential deterioration of clinical status.
Patients who are moderately to severely ill on arrival to the emergency department 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 retracting, as did this child. Patients should be hospitalized if they require beta-agonist therapy more often than four hours; and patients who require treatment more often than every two hours may require admission to an intensive care unit. This patient required treatments initially every 90 minutes. Further, patients with a requirement for supplemental oxygen also require care in an inpatient setting.