Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Upper Respiratory Infection and Trouble Breathing. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is a toddler male child. He presented to the ED (emergency department) with one-day history of congestion, subjective fever, cough, post-tussive emesis, and increasing shortness of breath. He was complaining of abdominal pain, his appetite was decreased, and he was not making as many wet diapers. The patient's vital signs included temperature 36.9, heart rate 132, respiratory rate 26, and 98% saturation in room air. Examination was significant for moist mucous membranes, mild retractions, decreased breath sounds, able to speak in full sentences, benign abdomen, no rashes, and non-focal neurologic exam. Respiratory viral panel returned positive for rhinovirus-enterovirus. He was treated with three doses of nebulized albuterol/Atrovent, one dose of dexamethasone, and one dose of ibuprofen. He continued to exhibit retractions and tachypnea after the steroids and DuoNebs, so the decision was made to admit to pediatrics for further management. Admission orders included albuterol MDI (metered dose inhaler) every three hours with family teaching, pulse oximetry every four hours, regular diet for age, and anti-pyretic as needed. He was demonstrating signs of respiratory distress upon admission but improved, weaning to treatments every four hours after about twelve hours. His appetite improved and he had no vomiting and no fevers. His examination improved, with no signs of distress. He was subsequently deemed stable for discharge.

The Inpatient Hospital Admission was not medically necessary in this case.

About half of all children experience an episode of wheezing in the first six years of life, often linked with a viral respiratory infection (e.g., respiratory syncytial virus, rhinovirus. Human metapneumovirus, influenza). Children may even experience recurrent episodes of wheezing as triggered by viral infection.
There are different classifications of wheezing in young children. Some children experience transient wheezing, others experience persistent wheezing. Persistent wheezing may be divided into two groups, IgE mediated (or atopic) and non-atopic. Treatment includes following asthma guidelines, although dosing may need to be tailored due to young age and small size. Inhaled steroids may be useful in reducing risk of viral-mediated wheezing. Leukotriene modifying agents may be helpful with a subgroup of children. Administration of macrolide antibiotics may reduce the 
risk of severe secondary lower respiratory tract infection in some children. Overall, there is a lot of interest in finding medications to reduce viral-mediated wheezing in children. This previously health young male child presented with signs and symptoms consistent with reactive airways disease, testing positive for rhinovirus-enterovirus. He remained symptomatic after standard treatments in the ED (emergency department) with bronchodilators and corticosteroids. While it was not unreasonable to monitor him in the hospital for positive response to treatment, he was overall hemodynamically stable with no evidence of impending respiratory failure, no need for supplemental oxygen, and no underlying chronic medical conditions. He did not require acute inpatient admission and could have been successfully managed at a lower level of care.