Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute respiratory failure, secondary to viral bronchiolitis and right lower lobe pneumonia
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is a female infant twin who is unvaccinated. She presented to the emergency department with a three-day 
history of runny nose and cough, and a one-day history of decreased intake, decreased urine output, diarrhea, and difficulty breathing. The mother reported temperatures of 106 and 107 at 
home, the patient was treated with Ibuprofen. Her brother had also been reported to be sick. The patient's vital signs included a temperature of 39.2 Celsius (102.5 Fahrenheit), a heart rate of 
163, and a respiratory rate 45 with a 94% (percent) saturation on room air. An examination was significant for playful activity, dry mucous membranes, crying with tears, coarse breath sounds on the right, wheezing bilaterally, subcostal retractions, benign abdomen, no rash, and non-focal neurologic exam. Laboratory evaluation revealed a white blood count (WBC) count of 16.8 K/uL (kilo per microliter), a platelet count of 353 K/uL, potassium level of 5.1, CO2 (carbon dioxide) level of 22, and a glucose level of 106. A performed chest X-ray was reportedly unremarkable, 
with no evidence of infiltrate. Venous blood gas revealed a pH (potential of hydrogen) of 7.36, and pCO2 (partial pressure of carbon dioxide) of 38.5. A viral pathogen panel was positive for non-Covid19 Coronavirus NL63. The patient was treated with Tylenol and an intravenous fluid bolus. She was placed on high flow nasal cannula at 10L (liters) with a FiO2 (fraction of inspired oxygen) of 0.26 and was admitted to the pediatric intensive care unit (PICU) for management of acute respiratory failure, secondary to viral bronchiolitis and right lower lobe pneumonia. Admission orders included maintenance intravenous fluids, Famotidine for gastrointestinal protection, initially nothing by mouth advancing to diet for age as tolerated, high flow nasal cannula 10L (liters) weaning as tolerated, continuous cardiorespiratory monitoring, follow-up cultures, and Ceftriaxone 75mg/kg (milligrams per kilograms). Overnight, her respiratory support was weaned to a high flow nasal cannula of 8L and a FiO2 0.35. She was allowed to feed orally, tolerating two to three ounces ad lib. The patient's fever spiked to 100.6. She maintained good urine output. She was able to wean further to high flow nasal cannula 6L, her diet was advanced, and her intravenous fluids were discontinued. She was treated with Albuterol every two hours and given 24-hours of steroids. By hospital day three, she was able to wean to 2Lpm (liters per minute) nasal cannula and was no longer requiring the Albuterol. She was transferred to the pediatric floor for ongoing management. She was weaned to room air upon arrival to the pediatric floor. She had no further desaturations or episodes of respiratory distress. She was deemed stable for discharge home on day #3 to complete total seven days cefdinir and follow-up in outpatient clinic in one day. The request for 
the hospital inpatient admission is under review. 

The requested health service of an Inpatient Hospital Admission
was considered medically necessary. 

This female infant presented with signs and symptoms consistent with viral bronchiolitis and examination concerning for secondary pneumonia. She was aggressively treated in the emergency department with non-invasive ventilatory support and admitted to the pediatric intensive care unit for ongoing care. The complexity of her condition, with both viral bronchiolitis and secondary pneumonia was most appropriately managed at acute inpatient level of care. She required supplemental oxygen, non-invasive ventilatory support, parenteral antibiotics, and intravenous fluid hydration. Lower level of care was not safe or appropriate in 
this case.