Diagnosis: Tachypnea with a viral illness

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This is a female with a history of autism spectrum disorder and speech delay. She had a history of a previous respiratory illness one month prior to this admission. She has been prescribed an albuterol metered dose inhaler in the past. She was sick for 2 days with a dry cough and nasal congestion. There were other siblings at home with similar symptoms. When she was noted to have labored breathing, she was brought to the ER (emergency room) for medical evaluation.

In the ER she was noted to have mild abdominal retractions and occasional suprasternal retractions. The mother indicated that she was acting like her chest was sore. She was afebrile with mild degree of tachycardia. The pulse oximeter reading in the ER was documented to be 96% (percent) with occasional drops to 93% on room air. She did not require oxygen supplementation. On physical exam she was not in distress and there was no audible wheezing upon chest examination. A respiratory viral panel was positive for rhino/enterovirus. She was treated with 2 back-to-back albuterol treatments and decadron. Since the mother did not have a nebulizer in the home and the child had been prescribed albuterol with a metered dose inhaler in the past and the mother indicated that she had difficulty administering this medication to her child, the decision was made to admit her with a diagnosis of Tachypnea with a viral illness for ongoing treatment with albuterol, every 3 hours and monitoring of her oxygen saturation.

An inpatient admission is not considered medically necessary for this patient.

This child was treated appropriately in the ER for a cough, and tachypnea. She was not in acute respiratory distress; she was drinking adequately and there was no ongoing need for oxygen supplementation. She could have been discharged home with an aerochamber and education in the appropriate treatment with albuterol with the metered dose inhaler she had previously been prescribed. There was also the option to prescribe a nebulizer for use in the home to permit the administration of albuterol. The medical record does not indicate that the possibility of the child having asthma was discussed with the mother. The decision to admit to the hospital was not consistent with the standard of care for a mild case of asthma related to a viral illness. The mother could have been instructed on how to administer the appropriate treatments to be continued at home and the recommendation for a follow up visit with the pediatrician in 24 to 48 hours. This child could have been safely discharged home with appropriate medication for treatment at home.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for an inpatient admission is upheld. Medical Necessity is not substantiated.