Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cough and fever (croup).
Treatment:  Inpatient admission.
The insurer denied the inpatient admission. 
 The denial is overturned. 

The patient is a female child that presented to the emergency department (ED) with one-day history of non-productive cough worse at night and fever to 102-103.  She was drinking and voiding at baseline.  Vital signs included temperature 40.9, heart rate 161, respiratory rate 48, and 97% saturation in room air.  Physical examination was significant for moist mucous membranes, regular heart rate and rhythm increased work of breathing with some belly breathing but no tripoding or posturing, stridorous breathing with decreased air movement in lungs bilaterally, intermittent barky cough, and non-focal neurologic exam.  She was placed in physician observation status at 1420 for difficulty breathing.  She was treated with racemic epinephrine, Decadron, ibuprofen, and Tylenol.  She was evaluated every one to two hours.  Laboratory evaluation was planned, but attempts at obtaining intravenous (IV) access and drawing blood were unsuccessful.  Respiratory viral panel was sent.  Chest x-ray was negative.  The patient was re-evaluated at 1636, noted to have expiratory wheezing after last racemic epinephrine treatment.  She did well with a DuoNeb treatment, so she was given two additional DuoNeb treatments, with subsequent improvement in respiratory rate and mild abdominal pulling.  She was reassessed an hour later at 1736, noted to have inspiratory stridor, and given a second racemic epinephrine treatment.  At this point she was discharged from physician observation and admitted to the pediatric ward for ongoing management of acute obstructive laryngitis (croup) with stridor and cough. 

Admission orders included antipyretics, continuous pulse oximetry, racemic epinephrine every four hours as needed, and regular diet as tolerated.  The respiratory viral panel returned negative.  The patient remained stable in room air.  She was observed overnight and had no recurrence of stridor or increased work of breathing.  She was deemed stable for discharge to follow-up with her pediatrician in one to two days. 

Yes, inpatient admission was medically necessary.

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.  Sudden onset stridor may represent foreign body aspiration, but there is no evidence of infection.  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 female child presented to the ED with signs and symptoms consistent with moderate to severe croup.  She responded well to racemic epinephrine but had return of symptoms necessitating a second treatment.  She was placed in observation in the ED and over the period of time that she was monitored, required two doses of racemic epinephrine with subsequent return of symptoms.  While her hospital stay was short and she remained hemodynamically stable with no need for supplemental oxygen, she failed management in the ED with return of symptoms twice after racemic epinephrine treatments.  Acute inpatient admission was medically necessary and appropriate.  She could not have been safely managed at a lower level of care.