Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cough and Wheezing (rhinoenterovirus).
Treatment: Inpatient admission.
The insurer denied: Inpatient admission.
The denial is upheld.

The patient is a toddler aged male child with medical history of tracheomalacia and one episode of anaphylaxis to an unknown substance. He presented with one-day history of difficulty breathing and audible wheezing, belly breathing and retractions. He was seen at another facility, diagnosed with bronchiolitis, and treated with dexamethasone and nebulized saline prior to 
discharge. He was given a prescription for amoxicillin for ear infection. There is a family history of asthma.
The patient's vital signs included temperature 36.8, heart rate 161, respiratory rate 60 with 96% saturation in room air. Examination was significant for moderate distress, tachycardia, wheezing, accessory muscle use, and non-focal neurologic exam. He was treated with albuterol/Atrovent with some improvement, decreased wheezing. He was given two additional combination treatments and a dose of dexamethasone. He was re-evaluated and was requiring albuterol every two hours. 
Laboratory testing was significant for enterovirus/rhinovirus respiratory pathogen panel. He was admitted for exacerbation of reactive airway disease. Admission orders included albuterol inhaler every two hours, continuous pulse oximetry, regular diet, no further antibiotics, and asthma action plan. Because the father was smoking outside, smoking cessation counseling was recommended. The patient was also referred to Allergy outpatient and prescribed an Epipen for home. Overnight he improved, with improved appetite and adequate urine output. He was able to tolerate spacing treatments to every four hours. He had no fevers and no evidence of ear infection. He was deemed stable for discharge.

The Inpatient admission was not medically necessary.

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. Treatment is generally supportive, including hydration, supplemental oxygen, and assisted ventilation when necessary (CPAP [continuous positive airway pressure], high flow nasal cannula oxygen, mechanical ventilation). Use of supplemental oxygen is at the clinician's discretion, particularly if oxygen saturation as measured by pulse oximetry is greater than 90%. There is no evidence to suggest that application of supplemental oxygen for 
saturation above 90% adds any benefit and may in fact prolong hospital stay. For this reason, continuous pulse oximetry is not considered standard. Antibacterial agents should only be used if 
there is a concomitant bacterial infection. Finally, hydration via enteral feedings and/or IV (intravenous) fluids is necessary.
While it was reasonable to monitor this child in the hospital for improvement versus worsening of symptoms, he was overall clinically stable, with no evidence of impending respiratory failure, no need for supplemental oxygen, and no fevers. He did not require acute inpatient admission and could have been safely managed at a lower level of care.