Diagnosis: Status asthmaticus

Treatment: inpatient admission

The insurer denied coverage for inpatient admission. The denial is reversed.

This patient is a male with a previous history of asthma and a previous hospital admission. The patient had been sick with a cough for several days. There were sick contacts in the home. When the child developed difficulty breathing and wheezing at home the mother administered albuterol. When there was no improvement in his shortness of breath the mother called an ambulance and he was taken to the Emergency Room (ER).

In the ER he was noted to be in respiratory distress with evidence of increased work of breathing and wheezing. His heart rate was elevated and his respiratory rate was 45. The ER physicians noted an increased work of breathing with wheezing and belly breathing. He was treated with 4 treatments with albuterol and atrovent and decadron. When there was no improvement in his respiratory distress and wheezing the decision was made to admit him to the hospital with a diagnosis of status asthmaticus for ongoing treatment with albuterol every 3 hours.

The insurer has denied the admission as not medically necessary and indicated that there was no documentation in the medical record to support the need for inpatient treatment.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The hospital admission is considered medically necessary for this patient.

The patient was treated appropriately in the ER for a cough, wheezing and respiratory distress. When there was ongoing respiratory distress with wheezing and increased work of breathing, it was appropriate and consistent with the standard of care to admit him to the hospital for ongoing treatment with albuterol every 3 hours. He was not stable enough to be sent home since the need for frequent albuterol administration could not have been safely administered in the home.

Based on the above, the medical necessity for the hospital admission is substantiated. The insurer's denial is reversed