Appeal type: Medical necessity
Decision: Upheld

Diagnosis: RSV infection, wheezing
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

No, the Inpatient admission was not medically necessary.

The patient is a child that was taken to the ED via ambulance because of belly breathing, a brief episode of apnea, and a brief episode of pallor/cyanosis. He had three day history of cough and an older sibling with cold symptoms. Vital signs included temperature 100.1 (spiking to 101.7), heart rate 161, and respiratory rate 40. Examination was significant for subcostal retractions, bilateral expiratory wheezing with good lung expansion, no nasal discharge, moist oral mucosa, and non-focal neurologic exam. Testing in the pediatrician's office earlier in the day was positive for RSV (Respiratory syncytial virus).

Laboratory evaluation revealed normal WBC (white blood count) (12.6K), mild metabolic acidosis (CO2 21), and elevated phosphorus (6.4). Venous blood gas revealed normal pH 7.373 and mildly decreased pCO2 (37). Rapid influenza and RSV testing was positive for RSV. He was treated with albuterol and Atrovent, with relief from wheezing. However, he remained mildly tachypneic with mild subcostal retractions. He was subsequently admitted with RSV bronchiolitis for monitoring because of possible apneic episode. 

Admission orders included spot pulse oximetry and close monitoring of respiratory status. He remained hemodynamically stable for the duration of his hospital stay, eating well, with no oxygen requirement, no increased work of breathing, and no pallor/cyanotic spells. He was afebrile and blood cultures were preliminary negative. He was deemed stable for discharge to follow-up with his pediatrician in one to two days.

On examination, there are signs of respiratory distress, including wheezing, nasal flaring, retractions, and tachypnea. If there is significant congestion, infants may exhibit signs of dehydration from inability to feed. Other than confirmatory testing for presence of RSV, laboratory investigation is not typically necessary. In young infants, however, urinary tract infection may accompany RSV infection, so in a febrile infant, urine studies are warranted. Chest x-ray is usually only necessary in the presence of significant fever, hypoxia, or underlying cardiopulmonary disease. A conservative approach to management is generally appropriate, particularly for the very young in whom apnea must be a consideration. Indications for hospitalization vary from institution to institution and practitioner to practitioner, with quite a bit of debate, but typically include the following: moderate to severe respiratory distress, including nasal flaring, tachypnea, retractions; hypoxia, with saturations less than 90-92%; poor feeding or dehydration; cyanosis; history of apnea; infants that are considered high risk either by very young age or underlying medical condition; poor social situation; severe malnutrition; and uncertainty over the diagnosis.
 
Treatment is generally supportive, including hydration, supplemental oxygen, and assisted ventilation when necessary (CPAP, high flow nasal cannula oxygen, mechanical ventilation). The current recommendation is not to use bronchodilator medications including epinephrine and albuterol because studies have failed to show sustained benefit. Hypertonic saline may be considered to facilitate mucociliary clearance. There is no place for corticosteroid administration because the evidence has shown no benefit when used alone and only tentative benefit when used in conjunction with bronchodilators. 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 fluids is necessary.
 
This male child presented with increased work of breathing and possible apneic episode associated with cyanosis. He tested positive for RSV in the clinic prior to coming to the ED. Apnea is not typically associated with older infants; it is most commonly seen in neonates and young infants. Because of the apparent apnea/bradypnea and associated color change, it was reasonable and appropriate to monitor him in the hospital. However, he was overall hemodynamically stable, with no evidence of impending respiratory failure, no recurrent spells, and no sign of sepsis. He did not require acute inpatient admission and could have been safely and appropriately managed at a lower level of care.