Diagnosis: Status Asthmatics

Treatment: Inpatient Admission

The insurer denied the inpatient admission. The denial was reversed.

This is a young female patient who presented to the Emergency Department (ED) after being evaluated at the Urgent Care Center for complaints of a cough for two days. It was reported that upon presentation the patient was noted to have moderate respiratory distress with increased work of breathing. Significant wheezing was noted on physical exam. Laboratory work up was performed revealing an elevated lactic acid level of 2.9. a respiratory viral panel was done which was negative. A computed tomography (CT) scan of the chest was done that showed a retrocardiac infiltrate versus atelectasis. She received nebulized treatments of albuterol and Atrovent, intravenous (IV) ceftriaxone, methylprednisolone and magnesium sulfate. It was reported that the patient continued with respiratory distress despite the medical intervention. She received IV fluid bolus and continuous albuterol for one hour. She was admitted to the Pediatric Intensive Care Unit (PICU) where she continued treatment with IV antibiotics, steroids and albuterol respiratory treatments. The patient was medically stabilized and discharged home.

Based on the review of the literature, the patient was treated appropriately in the ER for wheezing, respiratory distress and shortness of breath from asthma and pneumonia. However, it was noted that despite ER treatment with continuous albuterol and magnesium sulfate administration, the patient's symptoms was persistent and was concerning for respiratory deterioration. Literature indicates that patients, whose symptoms do not respond rapidly despite treatment with continuous beta-agonist nebulization therapy, should be closely monitored for worsening respiratory status. The literature indicates that the use of magnesium sulfate should be limited to those with severe asthma exacerbations while in the emergency department or for those who require ICU care.

At the emergency department, this patient received maximal care for her severe asthma exacerbation. This patient received continuous nebulizer treatment and magnesium sulfate. Despite this level of care, this patient's symptoms persistent, and required inpatient monitoring at the Pediatric Intensive Care Unit (PICU). Due to this patient's high risk for respiratory decline and potential need for ventilatory support, inpatient admission was medically necessary and consistent with the standard of care of treating for a pediatric patient with status asthmaticus.

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

The carrier's denial of coverage for the acute inpatient hospital is reversed. The medical necessity is substantiated.