Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bronchiolitis 
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient was taken to the emergency department (ED) for evaluation of increased work of breathing, fever to 104 degrees Fahrenheit, cough, wheezing, three episodes of vomiting, and decreased fluid intake. He had been seen in the ED the day before as well. Vital signs included a temperature of 38.3 degrees Celsius, heart rate 169 while crying, respiratory rate 35 while crying, and 98% oxygen saturation on room air. Examination was significant for a non-toxic appearance, no acute distress, moist mucous membranes, crackles overlying the right mid-lung field, intermittent tachycardia, intermittent tachypnea with subcostal retractions, and a non-focal neurologic exam.

A chest x-ray was obtained with perihilar interstitial opacities but no focal consolidation. Laboratory evaluation revealed metabolic acidosis with carbon dioxide (CO2) 16. Rapid testing for influenza, respiratory syncytial virus (RSV), and coronovirus disease (COVID) was negative. He was treated with Motrin after which he was able to tolerate something by mouth (PO). He became febrile again and was treated with Tylenol. He was admitted with diagnosis of bronchiolitis for observation and hydration. Admission orders included intravenous (IV) fluids, regular diet as tolerated, anti-pyretics, and respiratory score every two hours with escalation of treatment as necessary. He did well overnight with the resolution of fevers and no need for supplemental oxygen. He continued to do well and was deemed stable for discharge.

At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary. Bronchiolitis is an inflammatory process that affects predominantly small airways. Acute bronchiolitis is a clinical diagnosis given to the following constellation of signs and symptoms: viral upper respiratory prodrome followed by increased respiratory effort, wheezing, diffuse bilateral crackles, generally affecting infants less than 12-24 months of age. The most common causative agent is respiratory syncytial virus, but other viruses can cause bronchiolitis as well, including adenovirus, rhinovirus, influenza, enterovirus, parainfluenza, and human metapneumovirus. Non-viral causes include mycoplasma, chlamydia, fungi, and mycobacteria. Bronchiolitis typically starts in the upper airways and spreads to the lower airways within a few days, resulting in inflammation, edema, mucous production, and bronchospasm. Infants with bronchiolitis usually present with tachypnea, tachycardia, and prolonged expiratory phase. High fever is uncommon but can occur.

On examination, there may be signs of respiratory distress, including wheezing, nasal flaring, retractions, and tachypnea. If there is significant congestion, infants may exhibit signs of dehydration from inability to feed. Other than confirmatory testing for presence of RSV, laboratory investigation is not typically necessary. A chest x-ray is usually only necessary in the presence of significant fever, hypoxia, or underlying cardiopulmonary disease. A conservative approach to management is generally appropriate. Indications for hospitalization vary from institution to institution and practitioner to practitioner, with quite a bit of debate, but typically include the following: moderate to severe respiratory distress, including nasal flaring, tachypnea, retractions; hypoxia, with saturations less than 90-92%; poor feeding or dehydration; cyanosis; history of apnea; infants that are considered high risk either by very young age or underlying medical condition; poor social situation; severe malnutrition; and uncertainty over the diagnosis.

Treatment is generally supportive, including hydration, supplemental oxygen, and assisted ventilation when necessary (continuous positive airway pressure (CPAP), high flow nasal cannula oxygen, mechanical ventilation). The current recommendation is not to use bronchodilator medications including epinephrine and albuterol because studies have failed to show sustained benefit. Hypertonic saline may be considered to facilitate mucociliary clearance. There is no place for corticosteroid administration because the evidence has shown no benefit when used alone and only tentative benefit when used in conjunction with bronchodilators. Use of supplemental oxygen is at the clinician's discretion, particularly if oxygen saturation as measured by pulse oximetry is greater than 90%. There is no evidence to suggest that the application of supplemental oxygen for saturation above 90% adds any benefit and may in fact prolong hospital stay. For this reason, continuous pulse oximetry is not considered standard. Antibacterial agents should only be used if there is a concomitant bacterial infection. Finally, hydration via enteral feedings and/or intravenous (IV) fluids is necessary.

This young child presented to the ED twice with high fevers, poor oral intake, and respiratory symptoms. He exhibited increased work of breathing with the second presentation. He was admitted for observation and hydration. While this was a reasonable course of action, he was overall hemodynamically stable with no evidence of impending respiratory failure or sepsis and was not severely dehydrated. He did not require acute inpatient admission and could have been safely managed at a lower level of care.