Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Bronchiolitis.
Treatment:  Inpatient admission.

The health plan denied Inpatient admission.  The health plan's denial is overturned.

The patient is a female child born full term with history of bronchiolitis/hypoxia due to human metapneumovirus.  She presented to the ED with several day history of rhinorrhea and cough and one-day history of increased work of breathing and respiratory distress.  She had one episode of vomiting.  She had not eaten since the night before and had not voided either. 

The patient's vital signs included temperature 38.7 spiking to 39.1, heart rate 175, respiratory rate 48, and 94% oxygen saturation in room air.  Examination was significant for moist mucous membranes, supraclavicular and subcostal retractions, diffuse wheezing, transmitted upper airway sounds, tachypnea, benign abdomen, and non-focal neurologic exam.  She was placed in observation status in the ED for respiratory distress.  She was initially treated with DuoNeb and ibuprofen and evaluated every one-to-two hours. 

On re-assessment, the patient's retractions had improved, but she was tachypneic with wheezing throughout.  Pulse oximetry decreased to 88% while sleeping.  She was given a dose of Decadron and placed on high flow.  She remained tachypneic with retractions when next examined, and she did not tolerate an oral challenge with Pedialyte.  She was discharged from ED observation after approximately four hours to admit to the Intermediate Unit because of ongoing wheezing and need for high flow.  Respiratory viral panel was positive for rhinovirus/enterovirus, albuterol-responsive. 

Admission orders included albuterol every four hours, continued high flow with supplemental oxygen as needed, anti-pyretics, ad lib diet for age, and supportive care (nasal suctioning, chest physiotherapy, consideration for nebulized saline).  By the next day, the patient was able to wean from high flow/oxygen and was afebrile.  She was treated with a second dose of Decadron and continued treatment with albuterol.  Following family teaching, with stable saturations in room air while asleep, she was deemed stable for discharge home.  Discharge diagnosis was reactive airway disease secondary to rhinovirus/enterovirus respiratory infection.

Chest x-ray was unremarkable. 

This young child presented to the ED with cold symptoms followed by increased work of breathing and wheezing.  She was not drinking and had decreased urine output.  In the ED, she responded well to albuterol but continued to exhibit signs of bronchospasm necessitating initiation of high flow support.  She was also unable to tolerate an oral challenge.  She remained in the ED under observation for a number of hours.  When it became clear that her symptoms were not going to resolve sufficiently to discharge to home, she was admitted for further management.  She remained on high flow initially, and she was able to slowly wean to room air.  Testing revealed infection with rhinovirus/enterovirus, with symptoms responsive to bronchodilators.  She was cleared for discharge when she was able to remain free from supplemental oxygen while sleeping and able to tolerate fluids by mouth.  This level of care is most consistent with acute inpatient.  She had failed outpatient management and observation in the ED, requiring higher level of care.  The hospital stay was medically necessary and appropriate at acute inpatient level of care.