Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cough, Shortness of Breath.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient was brought to the emergency department (ED) for a cough for 2 days, fever and shortness of breath for 1 day. There was a history of decreased oral intake, with known sick contacts at home. During the emergency department (ED) evaluation, he was noted to have tachycardia to 183, he was noted to be in acute distress, with retractions, tachypnea, wheezing, rhinorrhea, and congestion. He was started on saline nebulizers (nebs). Lab results showed a slightly elevated white blood cell count, otherwise they were reassuring. A chest x-ray showed increased perihilar interstitial lung markings bilaterally. He was given an intravenous normal saline bolus and Ceftriaxone for concerns of clinical pneumonia, as well as Tylenol.

He was admitted with a diagnosis of bronchiolitis, reactive airway disease with a plan of continuing antibiotics until the cultures were negative for 24 hours, an Albuterol nebulizer every 3 hours, Motrin as needed, normal saline nebs as needed, intravenous fluids at 1 M (maintenance), high flow nasal cannula (HFNC) 4/21%, wean respiratory support as tolerated, suction as needed, vital signs every 4 hours. Upon arrival to the ED, he was saturating 95% on room air. He was given oral prednisone, the albuterol was spaced every 4 hours, and his respiratory viral panel returned positive for rhinovirus. He remained afebrile for 24 hours, with good oral intake and urinary output. He was discharged home with nebs, corticosteroids, and follow up with primary care physician (or provider) (PCP).

At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was not medically necessary.
This patient presented in mild respiratory distress and was admitted for concerns of bronchiolitis and clinical pneumonia. During the admission and ED evaluation, the patient remained hemodynamically stable. There is no clinical documentation to support that this patient required inpatient stay for hypoxemia, hypotension, cyanosis, or apnea. There was no history of comorbidity increasing the risk of morbidity or mortality. Although upon arrival to the ED, the patient was in distress, and there was concern for clinical pneumonia secondary to wheezing, fever, retractions, tachypnea and concerning chest x-ray results, the patient improved quickly within 24 hours. He quickly transitioned from albuterol every 3 hours to every 4 hours, tolerated oral intake, remained afebrile, and a chest x-ray was read as no consolidation and he was taken off Ceftriaxone.

The American Academy of Pediatrics (AAP) in 2014 revised their clinical practice guideline, "Diagnosis and Management of Bronchiolitis," originally published in 2006, for children. As per the AAP, most clinicians recognize bronchiolitis as a constellation of clinical signs and symptoms occurring in children. Viral upper respiratory tract prodrome followed by increased respiratory effort and wheezing, with clinical signs and symptoms of bronchiolitis consisting of rhinorrhea, cough, tachypnea, wheezing, rales, and increased respiratory effort (grunting, nasal flaring, and intercostal and/or subcostal retractions).

This patient was noted, in the ED, to have tachypnea, retractions, decreased air movement and wheezing, without mention of grunting, nasal flaring, apnea, or cyanosis or other signs of respiratory distress. The AAP has noted that an important issue to assess in the history is the effects of respiratory symptoms on mental status, feeding, and hydration. There was clinical documentation stating the patient had decreased oral intake, however, the physical exam did not mention the patient having exam findings of dehydration. Also of importance, noted by the AAP, is a history of underlying conditions, such as prematurity, cardiac disease, chronic pulmonary disease (bronchopulmonary dysplasia), congenital anomalies, immunodeficiency, or episodes of previous wheezing which has been associated with an increased risk of progression to severe disease or mortality. This patient did not have any significant past medical history, no history of previous wheezing, or other concerning factors that the AAP would consider as high risk.
The presence of a normal respiratory rate suggests that the risk of significant viral or bacterial lower respiratory tract infection or pneumonia in an infant is low (negative likelihood ratio approximately 0.5. (Fleming, Bonafide et al.). As per the American Academy of Pediatrics, tachypnea, defined as a respiratory rate greater than or equal to (>=) 70 breaths/per minute, has been associated with an increased risk of severe disease in some studies but not others. "Scoring systems have been developed in an attempt to objectively quantify respiratory distress, although none has achieved widespread acceptance and few have demonstrated any predictive validity, likely because of the substantial temporal variability in physical findings in infants with bronchiolitis." Although there was mention that this patient had tachypnea on physical exam, the vital signs do not show that this patient had significant tachypnea.
Lastly, infants with non-respiratory syncytial virus (RSV) bronchiolitis, in particular human rhinovirus, which is the case in this patient, appear to have a shorter course. The AAP states that current evidence does not support routine chest radiography in children with bronchiolitis. Chest x-rays in children with bronchiolitis may have abnormalities, data is insufficient to demonstrate that chest radiography correlates well with disease severity. One randomized trial suggests that children with suspected lower respiratory tract infection who had radiography performed were more likely to receive antibiotics without any difference in outcomes. The AAP recommends that "initial radiography should be reserved for cases in which respiratory effort is severe enough to warrant intensive care unit (ICU) admission or where signs of an airway complication (such as pneumothorax) are present."

Therefore, the patient did not require an inpatient stay and care could have been rendered at a lower level of care.