Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cough; runny nose; congestion; fever; diarrhea
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a male child that presented to the ED (emergency department) recently diagnosed with otitis media on amoxicillin, now with four-day history of cough, runny nose congestion, and fever, as well as three-day history of diarrhea. He was wheezing on the morning of presentation, with fever to 101.

The patient's vital signs included temperature 38.2, heart rate 132, respiratory rate 46 with 94% saturation in room air. Examination was significant for acute distress with nasal flaring and retractions, reduced air entry bilaterally, belly breathing, congestion, rhinorrhea, and posterior oropharyngeal erythema with exudate. Laboratory testing revealed positive RSV (respiratory syncytial virus). He was treated with two DuoNebs, as well as nebulized normal saline and dexamethasone prior to transfer to the pediatric floor for further management. Admission orders included regular diet, albuterol every six hours, amoxicillin, and nebulized saline every three hours. He remained stable in room air with good appetite and one episode of fever. He continued to do well and was deemed stable for discharge home.

No, the Inpatient admission was not medcally necessary.
Bronchiolitis is an inflammatory process that affects predominantly small airways. Acute bronchiolitis is a clinical diagnosis given to the following constellation of signs and symptoms: viral upper respiratory prodrome followed by increased respiratory effort, wheezing, diffuse bilateral crackles, generally affecting infants less than 12-24 months of age. The most common causative agent is respiratory syncytial virus, but other viruses can cause bronchiolitis as well, including adenovirus, rhinovirus, influenza, enterovirus, parainfluenza, and human metapneumovirus. Non-viral causes include mycoplasma, chlamydia, fungi, and mycobacteria. Bronchiolitis typically starts in the upper airways and spreads to the lower airways within a few days, resulting in inflammation, edema, mucous production, and bronchospasm. Infants with bronchiolitis usually present with tachypnea, tachycardia, and prolonged expiratory phase. High fever is uncommon.

On examination, there may be 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 (respiratory syncytial virus), laboratory investigation is not typically necessary. In young infants, however, urinary tract infection may accompany RSV (respiratory syncytial virus) 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 [continuous positive airway pressure], 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. However, if the child is considered to be at risk for atopic disease or exacerbation either by personal or family history, a trial of bronchodilator treatment is a reasonable course of action. For those that respond, an asthma pathway may provide significant benefit including steroids in addition to the bronchodilators. Hypertonic saline may be considered to facilitate mucociliary clearance. Antibacterial agents should only be used if there is a concomitant bacterial infection. Finally, hydration via enteral feedings and/or IV (intravenous) fluids is necessary.

This young child presented with signs and symptoms of acute respiratory distress, including wheezing, retractions, and nasal flaring. He had no oxygen requirement, and responded well to bronchodilator and nebulized normal saline therapy. While it was not unreasonable to monitor him for evolution of illness, he was overall hemodynamically stable with no evidence of impending respiratory failure, no need for supplemental oxygen, able to tolerate diet for age. He did not require acute inpatient admission and could have been safely managed at a lower level of care.

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