Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Difficulty breathing, Cough, Congestion and Viral Infection Human Metapneumovirus (HMPV)
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.  
The denial is upheld.

The acute inpatient admission was not medically necessary.
The patient is a female child that presented to Urgent Care on with several day history of fever to 102, congestion, and progressively increased work of breathing. The patient was treated with two doses of albuterol as well as dexamethasone with improvement in oxygen saturation and work of breathing. The patient's examination revealed bilateral acute suppurative otitis media for which she was prescribed Augmentin. The patient was referred to the emergency department for further management. In the emergency room, the patient's vital signs included temperature 37.8, heart rate 134, respiratory rate 30 with 93% saturation in room air. Examination was significant for no acute distress, non-toxic-appearing, moist mucous membranes, tachypnea, rhonchi and rales, and non-focal neurologic exam. The patient was placed on supplemental oxygen for desaturation to 90%.
She was noted to have a congested cough. Chest x-ray was obtained and was unremarkable. The patient was treated with normal saline bolus and admitted for further management of viral bronchiolitis.
Admission orders included supplemental oxygen as needed, follow-up respiratory viral panel and blood culture, maintenance intravenous fluids, and single dose of ceftriaxone for otitis media. The viral panel returned positive for human metapneumovirus. The patient was able to wean to room air by hospital day two. Her intake improved and intravenous fluids were discontinued. The patient was treated with albuterol every four hours and hypertonic saline every six hours. She had no fevers after the first day. She was deemed stable for discharge. 
Bronchiolitis is an inflammatory process that affects predominantly small airways. 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 respiratory syncytial virus, laboratory investigation is not typically necessary. Chest x-ray is usually only necessary in the presence of significant fever, hypoxia, or underlying cardiopulmonary disease.
Indications for hospitalization... typically include the following: moderate to severe respiratory distress, including nasal flaring, tachypnea, retractions; hypoxia, with saturations less than 90 to 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 (continuous positive airway pressure [CPAP], 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 intravenous fluids is necessary.
This young female child developed signs of respiratory distress secondary to infection with human metapneumovirus. She developed increased work of breathing and hypoxia, responsive to treatment with bronchodilators. While it was reasonable to monitor in the hospital for resolution of hypoxia and treatment for dehydration and bronchospasm, the patient was overall
hemodynamically stable with no evidence of impending respiratory failure, no persistent oxygen requirement, and no significant metabolic derangements. She did not require acute inpatient admission and could have been safely managed at a lower level of care.
The health plan did act reasonably, with sound medical judgment and in the best interest of the patient.