Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory Distress 
Treatment: Inpatient admission 
The insurer denied the inpatient admission.
 The denial was upheld. 

This is a female patient who presented to the Emergency Room (ER) with fever and a cough for several days. The child was noted to take less by mouth and had multiple episodes of vomiting after meals in the past day. In the emergency room (ER) the patient was noted to have stridor, grunting and retractions. The initial heart rate was elevated at 181 and the respiratory rate was 58. The pulse oximeter was 93%. On physical exam the child was noted to have nasal flaring and retractions with crackles heard upon auscultation of the right lung. A chest x-ray did not demonstrate any pneumonia and blood testing showed an elevated lactate of 3.09. A respiratory viral panel was positive for parainfluenza virus and rhino/enterovirus. Following treatment in the ER the patient was much improved and was tolerating oral fluids and did not have any evidence of dehydration. The patient was discharged. 

The decision was made to admit the child to the hospital for ongoing monitoring of the respiratory rate and vital signs. There was no plan for ongoing respiratory treatment during the planned hospitalization with a diagnosis of Croup related to an infection with the parainfluenza virus. 

The patient was treated appropriately in the emergency room for an acute episode of croup with moderate respiratory distress and stridor. The medical record clearly indicates the child's respiratory distress significantly improved and the child was resting comfortably and tolerated liquids by mouth. There was no plan for ongoing treatment to be administered during the hospitalization. There was a statement from one of the ER physicians that the parents had low health literacy which was a reason for the decision to want to observe the child in the hospital. 

This child was much improved following treatment and could have been safely discharged with a follow up visit with the pediatrician who knew the parents and the child well in 24 - 48 hours. The parents had demonstrated good clinical judgement in bringing their child to three ER visits when respiratory illness occurred. They could have been easily educated in appropriate ongoing care at home overnight and of the importance of seeking follow up with their pediatrician. 

According to Woods, "Croup (laryngotracheitis) is a respiratory illness characterized by inspiratory stridor, barking cough, and hoarseness. It typically occurs in children six months to three years of age and is caused by parainfluenza virus." 

Hospitalization Indications - Children with moderate/severe croup whose condition worsens or fails to improve as expected after treatment with nebulized epinephrine and corticosteroids should be admitted to the hospital for repeated doses of nebulized epinephrine, observation, and supportive care. Poor response to nebulized epinephrine in conjunction with high fever and toxic appearance should prompt consideration of bacterial tracheitis."

The decision to admit this child overnight for observation was not medically indicated and not consistent with the standard of care for croup related to a parainfluenza virus infection. 

The health plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.