Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory Distress. 

Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This is an infant who was born at 33 weeks gestation, who had coughing with nasal congestion for 4 days. The patient had been seen in the emergency room (ER) 3 days prior to the admission and was diagnosed with a respiratory syncytial virus (RSV)-related viral illness. The patient was considered stable at that time and was discharged home. The patient had been feeding well and having wet diapers but when they began to have vomiting episodes following eating and loose stools, the patient returned to the pediatrician for a follow up visit. The pediatrician noted retractions and arranged for the infant to be taken to the ER via emergency medical services (EMS) for further evaluation. In the ER, the patient was noted to have mild respiratory distress with tachypnea. However, the pulse oximeter reading was 100% and there was no documentation of hypoxemia during the time in the ER. On physical exam, the infant was noted to have rapid breathing with nasal stuffiness and mild abdominal and chest contractions.  A chest x-ray was obtained which showed a left perihilar infiltrate. The infant was started on oxygen supplementation at 7 liters. A repeat respiratory viral panel was positive for RSV and rhinovirus. The infant was tolerating oral feeds with no vomiting and an intravenous (IV) was not felt to be needed. When the patient continued to have an elevated respiratory rate, the decision was made to admit the infant to the hospital for ongoing treatment with oxygen with a diagnosis of bronchiolitis.

In this case, the patient was treated in the emergency room (ER) for coughing and increased work of breathing with oxygen supplementation. The patient's mild respiratory distress with increased work of breathing persisted despite oxygen supplementation. Because of the infant's history of premature birth at 33 weeks, the decision was made to admit the patient to the hospital for oxygen supplementation. 

The patient's newborn history did not indicate any respiratory problems and the infant was in the neonatal intensive care unit (NICU) to monitor for weight gain. The infant was tolerating oral feedings and was not documented to have hypoxemia during the period of observation in the emergency room (ER). There was no documentation of any treatment with nebulizer or nasal airway treatments during the time in the ER. The infant was documented as feeding and voiding well in the ER. There was no ongoing vomiting, no intravenous (IV) fluids were administered, and the medical record does not document that treatment with saline or suctioning of the nose was required.

The decision to admit the patient with a diagnosis of bronchiolitis for ongoing treatment with oxygen in the absence of documented hypoxemia is not consistent with the standard of care for an infant who was tolerating oral feedings and documented to have respiratory syncytial virus (RSV) for at least 3 days. The infant could have been safely discharged to home with nasal saline treatments and a plan for a follow up visit with the pediatrician in 24-48 hours. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.