Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Laryngotracheobronchitis
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a male with a family history of asthma and eczema and a medical history of croup, gastroesophageal reflux that resulted in neonatal hospitalization, and medication allergy. He presented to the emergency department (ED) with a one-day history of fever, croupy cough with stridor, and shortness of breath with perioral cyanosis that had resolved prior to ED arrival. He was given nebulized Albuterol at home before coming to the ED. He had been seen in an urgent care center the day before, and was diagnosed with otitis media, and started on Azithromycin. His vital signs included temperature 100.4, heart rate 168, respiratory rate 20, and 96 percent (%) saturation in room air.
The examination was significant for no distress, non-erythematous tympanic membranes, moist mucous membranes, regular heart rate and rhythm, croupy cough, clear lungs, no retractions or wheezing, benign abdomen, and non-focal neurologic examination. Four hours after arrival, he was noted to have stridor with rest. He was treated with Racemic Epinephrine and was reassessed. Two hours later, he was noted to have persistent stridor with supraclavicular retractions. The laboratory evaluation was significant for a white blood cell count (WBC) of 6.0, potassium 5.2, carbon dioxide (CO2) 15 and his glucose was 158. The viral respiratory pathogen panel was positive for parainfluenza type 3. The chest x-ray revealed a questionable right lower lobe opacity. He was given a dose of Dexamethasone and was admitted for further management of moderate croup with respiratory distress.
Admission orders included antipyretics, consideration for additional Racemic Epinephrine, routine vital signs, supplemental oxygen as needed. Overnight, his cough had improved. He was eating and drinking at baseline. He was afebrile with 100% saturation in room air. He continued to receive azithromycin. He had no further episodes of respiratory distress or stridor. He was subsequently deemed stable for discharge to follow-up with his pediatrician.

The acute inpatient hospital admission was not medically necessary. Croup, or laryngotracheobronchitis, is a viral infection of the glottis and subglottic regions and is the most common form of acute upper respiratory obstruction. Typically, patients start with upper respiratory tract infection symptoms, with runny nose, sore throat, cough, and low-grade fever. The "barking" cough then develops, including hoarseness and inspiratory stridor. Low grade fever may persist and may spike to 104. Symptoms are classically worse at night and persist for the better part of a week. Agitation worsens the symptoms. Croup is a clinical diagnosis, although neck radiographs may reveal typical subglottic narrowing ("steeple sign"). Although the differential diagnosis includes epiglottitis, these patients are typically ill in appearance, with drooling and tripod positioning. Sudden onset stridor may represent foreign body aspiration, but there is no evidence of infection. 

The patient has a history of croup presented with croupy cough and an episode of respiratory distress at home with associated perioral cyanosis. He was initially stable in the ED but upon reassessment was found to have stridor at rest. He was treated with Racemic Epinephrine with persistent stridor. While it was medically necessary and appropriate to monitor this child in the hospital with appropriate inhalational therapies, he was overall hemodynamically stable with no need for supplemental oxygen, no significant dehydration, and no evidence of impending respiratory failure. He did not require acute inpatient admission and could have been safely managed at lower level of care with ongoing respiratory treatments.