Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory
Treatment: Inpatient stay

This is a pediatric patient with a history of persistent asthma and multiple allergies who presented with difficulty breathing for 2 days. Patient reported cough and runny nose for the past 4 days. For difficulty breathing patient took Albuterol 2 puffs the night prior and the morning of presentation with no improvement. Paitent took 50 milligrams (mg) of steroids the evening prior with no improvement. The patient went to the primary medical doctor  office and was found to have oxygen  saturation of 90% and was sent by  PMD. In the emergency room (ER) patient was afebrile with respiratory rate (RR) 22 and O2 saturations 91-94% on room air. Physical exam was significant for intercostal retractions, decreased air entry bilateral  and wheezing. The patient received Combivent x 3 along with intravenous (IV) magnesium infusion, intravenous fluids (IVF) bolus and by mouth (PO) steroids. Within an hour the patient continued to wheeze and then was started on continuous albuterol along with 2 Liters of O2 via nasal cannula. The patient was transferred to the Pediatric Intensive Care Unit (PICU) for status asthmaticus. PICU attending reported patient with generalized wheezing with mild suprasternal retractions. Desaturations to 89% on room air. The patient was admitted to the PICU for status asthmaticus and hypoxemia and started on IVF, Albuterol every hour (q1hr), Atrovent q6hr, and Methylprednisolone 1mg/kg q6hrs. Respiratory viral panel (RVP) returned positive for enterovirus/rhinovirus. Patient was then weaned to Albuterol q2hrs on HOD #2. Pulmonology was consulted. Due to  improvement, the patient was downgraded to the pediatric floor for further monitoring. On the floor the patient was progressively spaced to Albuterol q4hrs and continued to have optimal oxygen saturation on room air. Paitnet was then cleared for discharge home on Qvar 2 puffs twice daily (BID) and albuterol 2 puffs q4hrs. The patient was also instructed to complete a course of oral steroids. Patient was instructed to follow-up (F/U) with PMD in 1-2 days and pulmonology in 2-4 weeks. The health plan determination is overturned in whole. The inpatient stay was medically necessary for this patient. This patient presented with significant respiratory distress and desaturation down to 90% on room air. Although the patient showed some improvement and appeared to respond to ER management, patient  still had wheezing and an oxygen requirement at the time of admission and was unable to last more than 1 hour without increased symptoms and treatment. The presentation was severe enough in the ER to require continuous albuterol along with IV magnesium infusion.
Patients who receive continuous albuterol and IV magnesium are those who present with significant risk of deterioration. The admitting physician felt the need to order Albuterol treatments every 1 hour as patient remained symptomatic with wheezing and saturations of 90% on room air after aggressive ER management. Treatments every hour along with continuous vital sign monitoring would constitute an inpatient admission. The literature recommends admission and close monitoring for patients with hypoxia and severe respiratory distress who do not respond appropriately to ER management in the face of an asthma exacerbation. Patients who receive continuous albuterol and IV magnesium are those who present with significant risk of deterioration. These patients are more likely to decompensate and require higher acuity of care once admitted. The patient still had wheezing and desaturation to 90% at the time of admission and required nebulizer treatments every hour. Such frequent treatments which would require increased monitoring and would not be appropriate for a lower level of care. For these reasons, inpatient stay would be medically necessary for this patient.