Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status Asthmaticus. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

This is a pre-school aged male with a history of asthma with a previous hospitalization for status asthmaticus. He also has a history of autism and Hemoglobin sickle cell (SC) disease. He was noted to be wheezing for one day at the shelter where he and his mother were residing, and he received one treatment with albuterol. He was then taken to school where he was coughing, and his wheezing was noted to continue. The mom decided to bring the child to the emergency room (ER) for additional treatment. 

In the emergency room (ER), he was noted to be in respiratory distress with suprasternal retractions and wheezing. On physical exam, the child was afebrile and had diffuse wheezing upon auscultation of the chest. He was treated with DuoNeb, and steroids followed by 2 additional treatments with albuterol. A chest x-ray was unremarkable, but a venous blood gas was significant for acidosis with a potential of hydrogen (pH) of 7.27 and a partial pressure of carbon dioxide (pCO2) of 51. In addition, his serum bicarbonate was low at 17 and his serum lactate was elevated at 4.6. Following treatment in the ER, because blood testing documented respiratory acidosis and ongoing wheezing and retractions, the decision was made to transfer the child with a diagnosis of status asthmaticus for continued treatment with albuterol every 2 hours. 

UpToDate article titled "Emergent evaluation and immediate management of acute respiratory distress in children" notes: "Respiratory distress in children, particularly neonates and infants, must be promptly recognized and aggressively treated because they may decompensate quickly. Factors that contribute to rapid respiratory compromise in children include smaller airways, increased metabolic demands, decreased respiratory reserves, and inadequate compensatory mechanisms as compared to adults. Respiratory arrest is the most common cause of cardiac arrest in children and outcomes are poor for patients who develop cardiopulmonary arrest as the result of respiratory deterioration. 
Vital signs - Respiratory rate, heart rate, blood pressure, temperature, and oxygen saturation give clues to the presence and etiology of respiratory distress. Respiratory rate - Normal respiratory rate varies by age. Tachypnea is one of the most important findings in children with respiratory disease. Tachypnea may also occur due to fever, activity, crying, cardiac disease, and metabolic acidosis. Apnea and bradypnea in neonates and infants with respiratory disease is usually the result of respiratory muscle fatigue. In neonates, particularly premature neonates' central immaturity is a common cause of apnea. In young infants, apnea may be the initial manifestation of bronchiolitis or pertussis." (3) 

The patient was treated appropriately in the ER for an acute episode of wheezing and difficulty breathing. The child has a history of a previous hospitalization for asthma. When he did not respond to treatment in the ER and he was noted to have an elevated lactate, a low bicarbonate and pH and persistent retractions, it was appropriate and consistent with the standard of care to admit the child to the hospital with a diagnosis of status asthmaticus for ongoing treatment with albuterol every two hours. He was not stable enough to be safely discharged to the shelter where he and his mother were residing. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.