Shortness of breath
Inpatient hospital

The patient is a girl who presented to the emergency department with shortness of breath. She was well until 2 days prior to admission when she developed rhinorrhea and congestion. She then developed cough with shortness of breath and chest tightness. She went to school on the day of admission, but was noted to have difficulty breathing and was sent to the emergency department for care. She had been prescribed albuterol several years ago, but was never diagnosed with asthma.

The health plan's determination is overturned. The Inpatient Hospital Admission was medically necessary for this patient. This is a young girl who presented with significant shortness of breath and wheezing. She was tachypneic and sitting upright upon presentation. She required intensive treatments in the emergency department including nebulized breathing treatments, corticosteroids, and magnesium sulfate. However, she continued to have significant wheezing and shortness of breath. She was therefore admitted to the hospital for ongoing intensive treatments and monitoring.
The decision making at the time of admission for this patient was consistent with her young age, the presence of significant wheezing and shortness of breath that persisted despite appropriate treatment in the emergency department, and the need for ongoing, frequent breathing treatments (every 3 hours) along with close monitoring for potential deterioration of clinical status.