Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Increased work of breathing, wheezing
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a male patient who was born at term; he was taken to the emergency department (ED) with a four-day history of a fever, cough, runny nose, and respiratory difficulty. His difficulty breathing had gotten worse over the prior two days, associated with audible wheezing. His appetite was poor, but he was drinking well with baseline urine output. Examination was significant for mild distress with wheezing, decreased air entry, mild subcostal and suprasternal retractions, mild pharyngeal erythema, regular heart rate and rhythm, benign abdomen, no rashes, non-focal neurologic exam.
 A chest x-ray revealed increased markings in the left lower lung field. He was treated with two doses of albuterol, one dose of DuoNeb, and methylprednisolone prior to admission to the pediatric floor for ongoing care. Admission orders included nebulized albuterol every two hours, Decadron every six hours, nebulized Atrovent every six hours, maintenance intravenous (IV) fluids. He slept well through the night, and the next day was noted to be better. His appetite had improved, he was able to wean to albuterol every four hours, and he was taking medications by mouth. He was deemed stable for discharge to follow-up with his doctor in two days. At issue is the medical necessity of an inpatient stay.
Inpatient hospital admission was not medically necessary for this patient.
About half of all children experience an episode of wheezing in the first six years of life, often linked with a viral respiratory infection (e.g. respiratory syncytial virus, rhinovirus. Human metapneumovirus, influenza). Children may even experience recurrent episodes of wheezing as triggered by viral infection.
There are different classifications of wheezing in young children. Some children experience transient wheezing, others experience persistent wheezing. Persistent wheezing may be divided into two groups, immunoglobulin (Ig) E mediated (or atopic) and non-atopic. Treatment includes following asthma guidelines, although dosing may need to be tailored due to young age and small size. Inhaled steroids may be useful in reducing the risk of viral-mediated wheezing. Leukotriene modifying agents may be helpful with a subgroup of children. Administration of macrolide antibiotics may reduce the risk of severe secondary lower respiratory tract infection in some children. Overall, there is a lot of interest in finding medications to reduce viral-mediated wheezing in children.
This young male child with family history of asthma presented to the ED with increased work of breathing and wheezing, testing positive for rhinovirus/enterovirus. He responded well to bronchodilator therapy and systemic steroids and was deemed stable for discharge the next day. While it was reasonable to monitor this child in the hospital for improvement of bronchospasm and reactive airways, he was overall hemodynamically stable with no need for supplemental oxygen and no significant dehydration. He did not require acute inpatient admission and could have been safely managed at lower level of care.