Diagnosis: Asthma
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is overturned.

The patient is a male with asthma who presented to the emergency department (ED) with shortness of breath and nasal congestion times 1 day. An Albuterol nebulizer had been given at home with little effect. The review of symptoms (ROS) was negative for fever, rash, vomiting, diarrhea, or cough.
The ED vitals were, temperature 37.7, heart rate (HR) 148, respiratory rate (RR) 24, blood pressure (BP) 132/74 and his peripheral capillary oxygen saturation (SpO2) was 98 percent (%) on room air. The examination noted tachypnea (30's) with decreased air movement and wheezing with mild flaring. The patient was treated with Decadron and DuoNeb times 3 for acute asthma exacerbation. Respiratory swab was negative for Influenza, respiratory syncytial virus (RSV) and Coronavirus (COVID).
The chest x-ray showed a right middle lobe (RML) infiltrate so Cefepime was also given. The patient remained tachypneic despite interventions so was also given intravenous (IV) Magnesium Sulfate and he was admitted to the inpatient unit on every three hour Albuterol for further care.

The inpatient admission was medically necessary for this patient. This patient with known asthma presented with asthma exacerbation and was also found to have community acquired pneumonia. He was treated appropriately in the ED for an acute asthma flare yet symptoms persisted despite adequate time for treatment. Given persistent symptoms and tachypnea, the patient required inpatient admission for continued close monitoring and treatment.
According to professional guidelines, pediatric asthma flares are based on signs and symptoms with disposition apparent within 2-4 hours of initiation of treatment. This patient remained with tachypnea and wheezing and increased respiratory effort, requiring an escalation of care while in the ED. Thus, his case required inpatient level of care.

The health plan's determination of medical necessity is overturned in whole.