Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breathing Problem
Treatment: Inpatient Hospital Services
The health plan denied: Inpatient Hospital Services
The determination is: Upheld

The patient is a female child with medical history significant for anemia, iron deficiency, and eczema who was taken to the emergency department (ED) with heavy breathing since the night before, vomiting since the morning, and upper respiratory infection (URI) symptoms for about a week. She was able to drink fluids but vomited after. She had not voided since the day before. She was taken to a clinic where she was given nebulized albuterol/Atrovent for wheezing with shortness of breath and referred to the ED. Her vital signs included a temperature of 36.2 Celsius, a heart rate of 127 beats per minute (bpm), and a respiratory rate of 30/minute with 100 percent (%) saturation in room air. Examination was significant for no acute distress, non-toxic appearance, moist mucous membranes, abdominal accessory muscle usage, prolonged expiration, diffuse wheezing bilaterally, benign abdomen, and non-focal neurologic exam. Laboratory evaluation was significant for a white blood cell (WBC) count of 17.75 with 90.8% neutrophils, a hemoglobin of 12.1, negative viral screen, a carbon dioxide (CO2) of 18, and a procalcitonin of 0.66. A chest x-ray was unremarkable. She was treated with three nebulized DuoNebs, nebulized saline, Decadron, and a normal saline bolus. She drank some Gatorade and some water in the ED but had a large emesis following the Decadron administration. She was admitted for rehydration and mild asthma exacerbation management. Admission orders included albuterol every four hours, prednisolone every 24 hours, ibuprofen as needed for fever, maintenance intravenous (IV) fluids, and repeat laboratory studies. She had an episode of vomiting and had poor oral intake overnight. The following day, she remained on IV fluids, azithromycin was added, and asthma education including use of an inhaler was ongoing. She remained afebrile. Her intake improved, and she was symptomatically improved. She was deemed stable for discharge to complete the course of azithromycin, continue albuterol inhaler every four hours for five days, complete five-day course of prednisolone, and follow-up in two to three days.
At issue is the medical necessity of the inpatient hospital services.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of inpatient hospital services is 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. Gas exchange abnormalities are due to ventilation/perfusion mismatch from atelectasis and airway over-distention. There are many possible triggers including exposure to allergens and upper respiratory viral infections. 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.
She was treated for asthma exacerbation in the ED but had ongoing distress and failed an oral challenge with a large emesis after being given Decadron. While it was reasonable to monitor her in the hospital for improvement with breathing treatments and IV fluids, she was overall hemodynamically stable without ongoing significant dehydration, and no evidence of impending respiratory failure. She did not require acute inpatient admission and could have been safely managed at an alternate level of care.