Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System - Asthma
Treatment: Inpatient Hospital

The health plan denied the inpatient hospital stay as not medically necessary.  The health plan's determination is upheld.

The patient is a female admitted for respiratory distress. Her past medical history includes premature birth at 34 weeks gestation, with a 1 month Neonatal Intensive-Care Unit stay for low birth weight and on nasal continuous positive airway pressure. This illness began 2 days prior to admission and progressed to heavy breathing and associated decreased oral intake and energy. There was no fever, nausea, vomiting, or diarrhea. At an outside hospital she was noted to have saturations to 83 percent (%) on room air, with moderate respiratory distress- tachypnea, accessory muscle use, as well as nasal congestion and wheezing. Viral testing for influenza and Coronavirus were negative. A chest x-ray showed peribronchial thickening and no consolidation. She was given an albuterol nebulizer 3 times and ipratropium once, as well as dexamethasone, magnesium sulfate, and terbutaline prior to arrival to this hospital. At the outside hospital,  she did not respond to a dose of albuterol. The rest of the medication was given en route by Emergency Medical Services (EMS). On arrival, she was noted to be in mild respiratory distress. Saturations were 88% but improved to 93% on 2 liters per minute (LPM) by nasal canula (NC). She was initially placed on albuterol every 2 hours but was quickly advanced to every 3 hours. The wheezing resolved. The patient was weaned off the 2LPM NC overnight. She received her last albuterol in the late afternoon. In the morning, the patient was on room air and was discharged home.

At issue is the medical necessity of the inpatient admission.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Inpatient Admission was not medically necessary for this patient.

According to the National Institute of Health (NIH) Asthma guidelines, patients that appear moderately to severely ill on arrival, and who have little improvement or worsen after initial therapy with beta-agonists and systemic glucocorticoids require hospitalization. This includes patients who continue to have significant wheezing and retracting and poor aeration after following NIH guidelines. The NIH guidelines recommend giving a patient up to 3 doses in the first hour of short acting beta agonist and corticosteroids. If there is no distress and the response is sustained 60 minutes after the last treatment, the patient can be sent to home. If there is incomplete response or mild to moderate symptoms, an individualized decision can be made towards admission. The NIH recommends physical exam findings such as the use of accessory muscles, inspiratory and expiratory wheezing, paradoxical breathing, cyanosis, and a respiratory rate greater than 60 as key signs of serious distress. Several severity assessment scores have been developed and tested in children to help predict the need for hospitalization early in the course of emergency department (ED) treatment.
This patient received 3 albuterol, corticosteroids, as well magnesium and Terbutaline upon arrival to this hospital. There was no response from albuterol in the ED. The accepting hospital provider documented that the patient showed continued mild respiratory distress. She was placed on albuterol every 2 hours and continued the asthma plan. Her saturations improved on 2LPM NC. She was hypoxic and requiring oxygen to keep her saturations above 93%. An alternate level of care as indicated by NIH guidelines was appropriate.

Thus, the requested health service/treatment of Inpatient Admission was not medically necessary for this patient.