Appeal type: Medical necessity
Decision: Overturned

Respiratory System - Influenza/Flu
Inpatient Hospital

The patient is a male with medical history significant for wheezing/reactive airway disease, allergies, and eczema that was referred to the emergency department (ED) by his pediatrician for evaluation of respiratory distress. He had several-day history of cough, congestion, and runny nose, with same-day history of increased work of breathing treated unsuccessfully at home with albuterol (administered every three to four hours). He also had some vomiting, one-day history of fevers, and cyanosis with cough. He was taken to the pediatrician who referred them to the ED. He was seen immediately because of high probability of imminent life-threatening deterioration (e.g. need for intubation).

Vital signs included temperature 40 C, heart rate 192, respiratory rate 42, and 95% oxygen saturation in room air. Examination was significant for sleepy, in respiratory distress, moist mucous membranes, decreased air entry bilaterally with suprasternal and subcostal retractions, hypoxic 89-90% in room air, and non-focal neurologic exam. He was treated with Decadron, three DuoNebs, ibuprofen, and a normal saline bolus, with additional albuterol as needed. Laboratory evaluation was notable for positive influenza A and rhinovirus/enterovirus. Chest x-ray demonstrated increased interstitial lung markings and peribronchial cuffing with no infiltrate. He was placed on ED Physician Observation Status for hypoxia with increased work of breathing and re-evaluated every one to two hours. Upon re-evaluation, he was noted to be tachycardic with decreased air entry bilaterally. He was started on high flow nasal cannula with fraction of inspired oxygen (FiO2) 0.40 titrated according to continuous pulse oximetry. He was examined a short while later and was found to be very comfortable. At this time, he was discharged from ED Observation and admitted to the Pediatric intermediate unit (IMU) for ongoing treatment of dehydration, acute bronchiolitis, and status asthmaticus. Admission orders included albuterol every two hours weaning as able, Tamiflu, anti-pyretics, intravenous (IV) fluids, supplemental oxygen as needed (had already weaned from high flow nasal cannula), and continuous pulse oximetry. Upon arrival to pediatric intermediate unit (PIMU), he was transitioned to FiO2 0.40 and appeared comfortable, with pulse oximetry 95%. Overnight, he remained on albuterol every two hours with nasal cannula 4 liters per minute (LPM) at 45%. The plan for the second day (4/2/19) was to wean supplemental oxygen from 0.45 to 0.30, continue albuterol every two hours, administer a second dose of Decadron, continue Tamiflu, continue IV fluids, and continue clear liquid diet. Over the course of the day, he was able to wean to simple nasal cannula with flow only (no supplemental oxygen) and transferred to the pediatric floor. Albuterol was weaned to every three hours and diet was advanced to regular for age. He continued to improve, weaning albuterol to every four hours, tolerating his diet. He was deemed stable for discharge to complete a course of Tamiflu.

The health plan's determination is overturned.

Influenza viral infection is a common viral respiratory illness caused by strains of influenza A or B with a broad clinical presentation for which immunization is recommended annually. Onset is typically acute, and associated with systemic symptoms such as fever, malaise, headache, myalgia, and decreased appetite. Sore throat and cough may be present from the beginning or may develop over the course of the illness. Gastrointestinal complaints may also be present, including nausea, vomiting, diarrhea, and abdominal pain. The most common complications include otitis media and pneumonia. Pneumonia may be viral or the result of secondary bacterial infection with staphylococcus (S.) aureus. Less common complications include myocarditis, encephalitis, myelitis, and Guillain Barre syndrome. Reye syndrome may occur with concomitant administration of aspirin-containing compounds. Antiviral agents are available, and if administered early in the course of illness (within 48 hours), decreased duration of symptoms and likelihood of complications. Additional treatment is supportive or related to concomitant complications or bacterial infection. Annual administration of influenza vaccine for prevention is encouraged.
This young male child with history of wheezing, eczema, and allergies, and family history of asthma became ill with both influenza A and rhinovirus/enterovirus and developed severe respiratory distress. His family treated him with albuterol every three to four hours without improvement. He continued to have retractions and cyanosis with cough. Upon presentation to the ED, he was hypoxia with significant bronchospasm. He improved with rapid sequence bronchodilators and high flow nasal cannula ventilatory support with supplemental oxygen. He was observed in the ED for several hours, and at the point that it was determined that he required ongoing non-invasive ventilatory support and supplemental oxygen, he was admitted to the intermediate care unit for further care. He remained in the PIMU until the third hospital day, when he had been weaned from oxygen and frequent bronchodilators. This degree of intervention and monitoring is most consistent with acute inpatient level of care. He had already failed outpatient and observation level of care.