Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System
Secondary: Breathing Problem
Treatment: Inpatient hospital stay
The patient has  a medical history significant for eczema and previous croup that presented to the emergency department (ED) with a four-day history of barking cough. The patient was given Orapred by the pediatrician four days prior to this presentation, completing two days of the course. Patient was seen in the ED the day prior to this presentation with stridor and increased work of breathing and was treated with two doses of nebulized epinephrine and a dose of Decadron with improvement, and discharged home. On this day, the patient again had difficulty breathing with stridor at rest, as well as decreased intake, so patient was taken back to the ED for evaluation. Vital signs included temperature 98.1, heart rate 160, respiratory rate 34 with 96% saturation in room air. Examination was significant for crying but consolable, well hydrated, moist oral mucosa, tachypnea, increased work of breathing with subcostal and intercostal and suprasternal retractions, stridor at rest, barky cough, good air entry bilaterally, audible rhonchi, and non-focal neurologic exam. Laboratory evaluation revealed leukocytosis with a left shift (white blood cell count 21.0 K with 59% neutrophils), mild metabolic acidosis (carbon dioxide (CO2) 22), and hyperglycemia (glucose 186). Paitent was treated with two doses of racemic epinephrine 90 minutes apart and a dose of Decadron. Plans were made to admit to the Pediatric Intensive Care Unit  but because the patient was still comfortable four hours after the second dose of racemic epinephrine, patient was admitted to the pediatric floor for further management having failed outpatient management. Admission orders included continuous pulse oximetry, regular diet for age, and racemic epinephrine as needed for stridor at rest. Patient did well overnight with one episode of noisy breathing (stridor or snoring) with no racemic epinephrine given. Patient remained afebrile and was able to tolerate adequate fluids by mouth. Paitent was sufficiently improved that he was deemed stable for discharge to follow-up with his pediatrician in one to two days. The health plan's determination is overturned in whole. Croup, or laryngotracheobronchitis, is a viral infection of the glottis and subglottic regions, and is the most common form of acute upper respiratory obstruction. Typically, patients start with upper respiratory tract infection symptoms, with runny nose, sore throat, cough, and low-grade fever. The "barking" cough then develops, including hoarseness and inspiratory stridor. Low grade fever may persist and may spike to 104. Symptoms are classically worse at night and persist for the better part of a week. Agitation worsens the symptoms. Croup is a clinical diagnosis, although neck radiographs may reveal typical subglottic narrowing ("steeple sign"). Although the differential diagnosis includes epiglottitis, these patients are typically ill in appearance, with drooling and tripod positioning. The mainstay of treatment of croup is airway management, with most children managed safely at home. For moderate to severe croup, racemic epinephrine may help to reduce laryngeal mucosal edema. Indication for administration is typically stridor at rest, hypoxia, respiratory distress, and impending need for intubation. Corticosteroids reduce edema through anti-inflammatory action. Oral steroids are beneficial even for mild cases of croup to shorten duration. Antibiotics are typically unnecessary for viral croup. For patients treated with racemic epinephrine, there is typically a period of observation after administration to monitor for recurrence of stridor at rest. This young  child with a history of croup and eczema again presented with croup. He was initially managed in the outpatient setting with enteral corticosteroids. Despite this treatment, the patient developed sufficient respiratory distress that the patient was taken to the ED. Patient was treated with racemic epinephrine and Decadron in the ED and discharged home after demonstrating sufficient improvement. Paitent returned the following day with increased work of breathing, respiratory distress with tachypnea and retractions, and poor oral intake. Patient was treated again with racemic epinephrine and a dose of Decadron in the ED, requiring a second dose of racemic epinephrine within 90 minutes. Initially, plans were made to transfer to the PICU because of the refractory nature of his stridor and respiratory distress, but  remained comfortable for four hours after the second dose so was admitted to the pediatric floor instead. Because of the persistent nature of this child's symptoms, the failed outpatient management with two days of Orapred, and again failed management following the first ED visit, acute inpatient admission was warranted and medically necessary, consistent with the current standards of care. Lower level of care had previously failed and would not have been sufficient.