Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchitis, Respiratory failure.

Treatment: Inpatient hospital admission.

The insurer is denied coverage for inpatient hospital admission. 

The denial is overturned.

This is a male patient who has a left cystic kidney and has been only partially vaccinated. He had been treated with two recent courses of antibiotics for otitis media.
Following vaccination he developed a rapid respiratory rate and grunting and was brought to the Emergency Room (ER) for evaluation. In the ER he was noted to be in moderate respiratory distress with retractions. His temperature was 102 degrees and he was breathing at a rate of 55 breaths per minute. He had a chest x -ray and a chest CT scan which were normal and blood testing was significant for a HCO3 of 19 and a lactic acid level of 2.5.There were 5 - 10 white blood cells noted on his urinalysis. He was treated with 2 boluses of normal saline, high flow oxygen and intravenous (IV) antibiotics. His respiratory distress did not improve following treatment in the ER, he was made to admitted to the PICU for ongoing treatment with antibiotics, IV fluid and oxygen with a diagnosis of Bronchiolitis and Respiratory failure. After a period of medical stability he was discharged with follow up instructions.


UP TO DATE: Clinical features, evaluation, and diagnosis of sepsis in term and late preterm infants.

"INTRODUCTION - Sepsis is an important cause of morbidity and mortality among newborn infants. Although the incidence of sepsis in term and late preterm infants is low, the potential for serious adverse outcomes, including death, is of such great consequence that caregivers should have a low threshold for evaluation and treatment for possible sepsis in neonates."

UP TO DATE: 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].
INDICATIONS FOR HOSPITALIZATION
Although clinical practice varies widely [13-15], hospitalization for supportive care and
monitoring usually is indicated for infants and young children with [2,16]:
1)Toxic appearance, poor feeding, lethargy, and dehydration.
2)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.
3)Apnea.
4)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."

UP TO DATE: Emergent evaluation and immediate management of acute respiratory distress in children.

Based on the above, the medical necessity for the inpatient hospital admission is substantiated. The insurer's denial is overturned.