Diagnosis: Asthma.

Treatment: Inpatient admission.

The insurer denied the inpatient admission.

The denial was reversed.

This is a young male patient with a history of obesity and asthma. It was reported that the patient had a recent admission to the Pediatric Intensive Care Unit (PICU) for an asthmatic episode. The patient was maintained on daily inhaled flovent. The patient had been sick with coughing and had 4 episodes of vomiting at school. The patient presented to the Emergency Room (ER) for evaluation and treatment of rapid breathing. It was reported that the patient was given albuterol at home but his wheezing did not improve. In the ER, the patient was noted to be in moderate distress with suprasternal retraction, expiratory wheezing and decreased breath sounds. The patient was treated with 3 doses of inhaled duoneb and decadron. The patient's blood gas was significant for acidosis with a pH of 7.22 and an elevated pCO2 of 49.9. The patient's white blood cell (WBC) count was elevated at 17,000. The patient's lactic acid level was elevated at 8.4 and his HCO3 was low at 17 which confirmed the presence of a metabolic acidosis. The patient's respiratory distress did not improve in the ER; the patient with admitted to the hospital with a diagnosis of status asthmaticus and metabolic acidosis. He was treated with intravenous (IV) fluids and albuterol every 2 hours.

Based on the review of the medical record, the patient was treated appropriately in the Emergency Room (ER) for a cough, wheezing and respiratory distress. When there was ongoing respiratory distress with wheezing and increased work of breathing and blood testing confirming the presence of metabolic acidosis, it was medically appropriate and consistent with the standard of care to admit the patient to the hospital for ongoing treatment with albuterol every 2 hours. The patient was not stable enough to be sent home in view of his metabolic acidosis and need for frequent dosing of albuterol. Thus, the literature supports that inpatient admission was medically necessary for this patient.

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

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