Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Respiratory/Asthma.
Treatment:  Inpatient stay.
The insurer denied inpatient stay.  The denial was overturned.

This is a pediatric patient with a history of eczema who presented to the emergency room (ER) from a local urgent care center with complaints of shortness of breath.  As per the mother, cough developed 4 days prior, and it progressively worsened.  Mother was giving treatments at home, but it was not helping.  Mother reported that the patient had not had any prior hospitalizations but had been treated with oral steroids in the past.  On the day of admission, the patient had shortness of breath that developed along with tactile fevers, decreased appetite and decreased activity.  Patient received 2 albuterol treatments and oral prednisone at the urgent care prior to being referred to the ER.  While in ER patient was found to be in respiratory distress with subcostal retractions.  Vitals revealed temperature 100.8, heart rate (HR) 140, respiratory rate (RR) 32, and oxygen (O2) saturation 100% on room air.  Patient was described as crying with weak cry and lethargic.  Patient was with diffuse expiratory wheezing and prolonged expiratory phase.  Patient was treated with intravenous (IV) steroids and albuterol treatment.  He continued to have increased work of breathing (WOB), so another albuterol treatment was ordered.  Mom was unable to restrain the child to keep him from pulling off nasal cannula.  He finally became pale and his head went back, he was then placed on 100% nonrebreather face mask (NRBFM).  O2 sat was recorded as low as 88% at this time.  A high flow nasal cannula (HFNC) was ordered, but patient was uncooperative and did not tolerate this, so O2 was administered by blow by.  Another albuterol treatment was given, and patient was then given a dose of IV magnesium.  In all, patient received duo nebs x 3, IV magnesium and Methylprednisolone.  Patient was started on high flow oxygen and admitted to the pediatric service.  He was diagnosed with status asthmaticus and maintained on albuterol q2 hrs., systemic steroids and intravenous fluids (IVF).  While admitted he was continued on IV steroids and albuterol treatments.  Respiratory Viral Panel (RVP) returned positive for Rhinovirus.  The health plan's determination of medical necessity is overturned in whole.  The requested health service/treatment of inpatient stay is medically necessary for this patient.  This patient presented with respiratory distress that was not responding to nebulizer treatment and systemic steroids administered in the ER.  The patient continued to worsen and then became hypoxic and was placed on a non-rebreather mask.  HFNC was ordered, patient was uncooperative and was placed on blow by O2 35%.  Then the patient was placed on Albuterol treatments every 2 hours. Treatments every two hours along with frequent vital sign monitoring while on supplemental oxygen would constitute an inpatient admission.  This child, upon presentation, was in severe enough respiratory distress to require IV magnesium.  These patients require closer monitoring as they are at risk for relapse and deterioration. This condition would warrant a higher level of care.  The literature recommends admission and close monitoring for patients with persistent respiratory distress in the face of an asthma exacerbation after proper ER management has been implemented. Progression of his disease process and/or worsening is of very great concern and not appropriate to be managed at a lower level of care.