Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory Syncytial Virus (RSV)

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

The patient is a male infant with a history of nasal congestion and a cough for 3 days. The mother indicated that the child was crying often and not eating as well as normal during this illness. When the mother noted that he started to breath fast she brought him to the Emergency Room (ER).

In the ER, he was noted to have persistent respiratory distress with a low oxygen saturation of 90% (percent) when sleeping. On physical examination he was noted to be tachypneic and to have thick white discharge from both nares of the nose. There was bilateral wheezing and coarse breath sounds. He tested positive for the respiratory syncytial virus (RSV) virus. A chest x-ray demonstrated increased pulmonary markings. He was treated with nasal saline suctioning and nebulization with normal saline. When his low oxygen saturation persisted despite treatment with oxygen supplementation in the ER the decision was made to transfer him for admission with a diagnosis of RSV bronchiolitis for continued treatment with oxygen.

According to UpToDate article Bronchiolitis in infants and children: Treatment; outcome; and prevention, "SEVERITY ASSESSMENT - Severe bronchiolitis is indicated by persistently increased respiratory effort (tachypnea; nasal flaring; intercostal, subcostal, or suprasternal retractions; accessory muscle use; grunting), hypoxemia, apnea, or acute respiratory failure [1,2]. 

Risk factors for severe disease and/or complications of bronchiolitis include [3-8]:

-	Prematurity (gestational age <37 weeks)
-	Age <12 weeks
-	Chronic pulmonary disease, particularly bronchopulmonary dysplasia (also known as chronic lung disease)
-	Congenital and anatomic defects of the airways
-	Congenital heart disease
-	Immunodeficiency
-	Neurologic disease

INDICATIONS FOR HOSPITALIZATION - Children can be managed as outpatients if they are adequately hydrated and have no signs of moderate to severe respiratory distress (eg, nasal flaring; retractions; grunting; respiratory rate >70 breaths per minute; dyspnea; or cyanosis) and do not require supplemental oxygen [2]. Infants with bronchiolitis who are not hospitalized should be monitored in the outpatient setting by their clinician for progression of disease.

Although clinical practice varies widely [13-15], hospitalization for supportive care and monitoring usually is indicated for infants and young children with [2,16]:

-	Toxic appearance, poor feeding, lethargy, and dehydration.

-	Moderate to severe respiratory distress, manifested by one or more of the following signs: nasal flaring; intercostal, subcostal, or suprasternal retractions; respiratory rate >70 breaths per minute; dyspnea; or cyanosis.

-	Apnea.

-	Hypoxemia with or without hypercapnia (arterial or capillary carbon dioxide tension >45 mmHg). Studies evaluating SpO2 (oxygen saturation) <95 percent as a predictor of disease severity or progression among outpatient children with bronchiolitis have inconsistent results [3,17]; nonetheless we use SpO2 <95 percent on room air at sea level as a threshold for admission."

The patient was treated appropriately in the ER for respiratory distress with hypoxemia and in view of the persistent low oxygen saturation, despite treatment with supplemental oxygen. The decision to admit was consistent with the standard of care for a young infant with bronchiolitis and hypoxemia. The decision to admit to the hospital for ongoing treatment with oxygen therapy was appropriate since the child was not stable enough to be discharged to the home. 

The health care plan did not act reasonably, with sound clinical judgment, and in the best interest of the patient.

The insurer's denial of coverage for the inpatient admission is overturned. Medical necessity is substantiated.