Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Respiratory System
Treatment:  Inpatient Hospital
The insurer denied the inpatient admission. The denial was overturned.
  
The patient is a female with a history of febrile seizures who presented with cough, breathing problems, and fever.  She was well until 3 days prior to admission when she developed cough and congestion.  She then developed fever and trouble breathing.  Her cough was worse at night.  She was given albuterol at home 3 times, with minimal relief.  Her temperature went up to 103 Fahrenheit (F) at home, and she was brought to her primary care physician's office.  She was subsequently referred to the emergency department, due to continued fever and trouble breathing.

In the emergency department, her physical examination revealed tachypnea with respiratory distress and retractions, decreased air movement, wheezing, and rales that were worse on the right compared to the left.

She received 2 albuterol/Atrovent nebulized treatments, and a chest x-ray, and blood work was obtained.  She also received an intravenous fluid bolus.  The x-ray was consistent with a viral illness versus reactive airways disease.  Following treatment, she continued to have retractions and tachypnea; she was, therefore, given a dose of ceftriaxone and admitted for further care.

On the pediatric floor she continued to have tachypnea, retractions, cough, and congestion.  She was treated with ceftriaxone, as well as albuterol nebulized treatments and intravenous fluids.  Due to continued high fevers up to 103F, a partial sepsis evaluation was done.  Her respiratory symptoms worsened during admission; therefore she was started on continuous albuterol therapy for a period of time, and Solu-Medrol was added.  She subsequently improved and was able to wean to every 2 hour treatments, and then advanced every 3 and then every 4 hour treatments.  She was continued on ceftriaxone until her blood cultures were negative for 48 hours.  She was felt to be stable for discharge to home with follow-up as an outpatient.

The health plan's determination is overturned.

The requested health service/treatment of inpatient stay was medically necessary for this patient.  This is a very young patient who presented with cough, fever, and respiratory distress.  She continued to have significant respiratory symptoms despite receiving appropriate treatment both at home with albuterol, and in the emergency setting with both albuterol/Atrovent nebulized treatments and a fluid bolus.  She required hospital admission for ongoing treatment with frequent bronchodilators, intravenous fluids, and further escalation of treatment as needed.  In fact, during the hospitalization she had worsening of her respiratory symptoms and required continuous albuterol for a period of time, as well as the addition of intravenous Solu-Medrol.  Patients requiring bronchodilators at this frequency require inpatient care, due to the risk of deterioration and the need for close monitoring with additional treatments as needed; they are not appropriate for a lower level of care setting.

The decision-making at the time of admission for this patient was consistent with her young age, the presence of continued respiratory distress despite appropriate therapies, and the need for ongoing intensive treatment with close monitoring for potential deterioration of clinical status.