Practice Guidelines, Managed Care, and Utilization Review
"While you were Wheezing"
If Janie deteriorates over the next few hours while under observation in the hospital, you or the Utilization Review Nurse should contact the UR Office of Texas Starfighters. They need to be updated on Janie's condition and on the interventions which have failed. It would be important to give them the following information:
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Physical exam pertinent to the reason for admission, including signs of respiratory distress such as use of accessory muscles, pulsus paradoxus.
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Pulse oximetry on room air and supplemental oxygen.
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Abnormal chest x-ray findings such as pneumonia, pneumothorax, signs of hyperinflation or air trapping.
It is likely that, had these findings been present in the ER and communicated
to the Managed Care Organization at that time, the admission would have been
authorized. If, however, you are still denied a full admission, your
next level of appeal is the Medical Director of the Managed Care Organization.
In the unlikely event that further communication does not clarify the situation,
Texas Law provides that a third review be conducted by a physician of like
specialty (i.e. a Pediatrician or Pediatric Asthma Specialist).