Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchiolitis.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female infant born prematurely with medical history significant for small PDA (Patent ductus arteriosus)/PFO (patent foramen ovale)/mild mitral valve insufficiency/mildly dilated right ventricle. She presented to the ED (emergency department) with two-day history of worsening cough, congestion, difficulty breathing, decreased intake, and one episode of vomiting. She had no fevers. Siblings were sick with similar symptoms earlier in the week.

The patient's vital signs included respiratory rate 60s, heart rate 170s, saturation 95% and above in room air. Examination was significant for global retractions and nasal flaring.

The patient was placed on high-flow nasal cannula (HFNC) with FiO2 (fractional inspired oxygen concentration) 0.37 at 2L/kg (liters per kilogram) with improvement in her respiratory distress symptoms. Chest x-ray was unremarkable, venous blood gas was reassuring, CBC (complete blood count) revealed mild neutropenia (WBC [white blood count] 12K [thousand] with 12% neutrophils), and metabolic panel was significant for elevated liver enzymes. Respiratory viral panel was positive for RSV (respiratory syncytial virus).

The patient was admitted to the PICU (pediatric intensive care unit) for further management of acute respiratory failure requiring HFNC (high-flow nasal cannula). Additional admission orders included IV (intravenous) fluids, nothing by mouth, famotidine, and repeat labs.

Overnight, the patient was weaned from 10L (liters) HFNC (high-flow nasal cannula) to 2L (liters) with minimal respiratory distress. She was allowed to eat by mouth, and IV (intravenous) fluids were decreased. She was transferred to the pediatric ward for continued care. Following transfer, she was weaned successfully to room air. Repeat blood work demonstrated ongoing transaminitis. Although attributed to acute viral infection, additional laboratory evaluation (following GI [gastroenterology] consultation) was performed for other possible causes. She continued to improve and was subsequently deemed stable for discharge to follow-up with GI [gastroenterology] and primary care.

Yes, acute inpatient admission and hospitalization was medically necessary and appropriate.
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 ex-premature young female infant presented with signs and symptoms of significant respiratory distress and impending acute respiratory failure. She responded well to high-flow nasal cannula with supplemental oxygen and within two days had successfully weaned to room air, able to tolerate her formula. Her illness was complicated by persistently elevated liver enzymes of unclear significance, eventually attributed to acute viral infection. Subsequent potential causes of hepatitis were ruled out. Based on current standards, the care that this infant required during her hospital stay was most consistent with acute inpatient level of care. Lower level of care would not have been appropriate in this case, regardless of the length of the hospital stay.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.