Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Viral Bronchiolitis 
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a male that was taken to the emergency department (ED) with one-week history of runny nose, five-day history of bilateral eye discharge, and one-day history of fever, cough, and rapid breathing. His vital signs included temperature 39.8, heart rate 195 and his respiratory rate was 30. The physical examination was significant for fussiness with profuse rhinorrhea and crusted bilateral eye discharge, left ear with impacted cerumen, mild pharyngeal erythema, bilateral conjunctival injection, tachycardia, tachypnea, intercostal retractions, rales, good perfusion, and non-focal neurologic examination. He was treated with Tylenol and Polytrim drops for his eyes.

The blood culture was pending. The chest x-ray was unremarkable. He was treated with nebulized Saline, Dexamethasone, and a Normal Saline bolus prior to admission for further management of acute viral bronchiolitis. Admission orders included continuous cardiorespiratory monitoring, regular pediatric diet, intravenous (IV) fluids at half-maintenance, supplemental oxygen, follow-up blood culture, nebulized Saline every three hours, and Tylenol as needed.
Following admission, he was noted to be persistently tachycardic with a heart rate in the 130's-140's. His brain (or B-type) natriuretic peptide (BNP) and troponin levels were obtained, but the sample was insufficient to run the troponin. The BNP was elevated at 667. The electrocardiogram was obtained with machine reading as follows: sinus bradycardia (heart rate 86) with sinus arrhythmia and left ventricular hypertrophy. Pediatric cardiology was contacted with recommendations to trend troponin and BNP, with plans to perform an echocardiogram later that day. The BNP had increased to 801.0 with a troponin that was less than (<) 0.012. The echocardiogram was unremarkable. Overall, his respiratory difficulties had resolved, his appetite was improving, he was overall stable. 

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.
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. The chest x-ray is usually only necessary in the presence of significant fever, hypoxia, or underlying cardiopulmonary disease. 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 percent (%); 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.