Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma Exacerbation. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

The patient has a prior history of asthma who was brought to the emergency department (ED) by Emergency Medical Services (EMS) with chest tightness, shortness of breath, and wheezing. She had not been taking inhaled steroids at home as prescribed. She did not have a fever, upper respiratory infection (URI) symptoms, or gastrointestinal (GI) symptoms. At triage, her vital signs were normal and oxygen saturation was 100% on oxygen. She was described as in acute distress-moderate respiratory distress with tachypnea, prolonged expiration, decreased air movement, and wheezing. Capillary refill was less than 2 seconds (sec). On reassessment, after receiving intravenous (IV) steroids, three nebulizer treatments, and magnesium sulfate (MgSO4) and a normal saline bolus, she still felt dizzy and short of breath on ambulation, and still had diminished air entry, although the lung exam was improved. She was admitted to the pediatric floor for further management. 
The admission history and physical (H&P) provides the further history that she had been living in her grandmother's basement where she is exposed to mold and dust, which along with cockroaches and animal dander, are her typical asthma triggers. The physical exam had vital signs that were normal, except for a mildly increased heart rate. The oxygen saturation was 99% on room air. The lung sounds were normal except for decreased air movement. Coronovirus disease (COVID), flu, and respiratory syncytial virus (RSV) swabs were negative. The impression was acute exacerbation due to noncompliance with her controller medication (Flovent) and exposure to dust and mold.
She was seen by pulmonology. The consultant noted normal vital signs, normal oxygen saturation, the absence of respiratory distress, normal appearance, and normal lung exam. The impression was mild persistent asthma with an exacerbation due to suboptimal use of her controller medication and exposure to mold/dust. Education to the parents and patient is documented regarding the use of the controller medication and rescue medication delivered via metered dose inhaler (MDI) with a spacer, as well as use of the nebulizer with either the controller or rescue medication nebulizer from the liquid form. Allergy medications, antihistamine, nasal steroid, and montelukast, were added to the regimen. The plan was for outpatient pediatric pulmonary follow up in 7 days. The patient was not discharged home at this time; there is a notation that this was due to the parents not filling the medication prescriptions. 

At issue is the medical necessity of an inpatient stay. 

An inpatient stay was not medically necessary. 

The patient had known allergic rhinitis and mild persistent asthma. She was not taking her controller medications (inhaled steroids), so she was more susceptible to an acute exacerbation when she was exposed to her regular allergic and asthma trigger-the dust and mold in the grandmother's basement. While she came by EMS, on oxygen, and arrived in the ED in moderate respiratory distress, she was treated aggressively in the ED and was admitted to the pediatric floor only because she still felt short of breath after all the treatment she received. By the time she arrived on the floor, she was no longer in distress, no longer required oxygen, and only had some diminished air entry on lung exam. She was provided continued asthma treatments that she would otherwise have received at home overnight and by the next day, according to the consulting lung specialist, was ready for discharge on her asthma and allergy medications, with outpatient follow up in 7 days. Care could have been provided at a lower level of care.