Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cough and Trouble Breathing
Treatment: Inpatient admission

The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male child with medical history significant for intermittent asthma and sickle cell trait that presented to the emergency department (ED) with one-day history of fever to 104, cough, congestion, one episode of post-tussive emesis, and rhinorrhea. He was given albuterol in clinic and again via Emergency Medical Services (EMS) without significant improvement. He had been seen the day prior for cough without significant distress and had been discharged. 

The patient's vital signs in the emergency department (ED) included temperature 38, heart rate 152, respiratory rate 52, and 93% (percent) saturation on room air. Examination was significant for no acute distress, congestion, moist mucous membranes, tachycardia, tachypnea with prolonged expiration, respiratory distress with retractions, decreased air movement, wheezing and rhonchi, and non-focal neurologic exam. He was treated with three DuoNebs and Decadron for acute asthma exacerbation. 

The patient's chest x-ray was obtained revealing a small area of consolidation in the right middle lobe with loss of sharp definition of the right heart border, atelectasis versus pneumonia. Laboratory evaluation was significant for white blood cell (WBC) count 11.9 thousand (K), left shift with 95.5% neutrophils, hyperglycemia with glucose 205, mild hypokalemia with potassium 3.2, metabolic acidosis with carbon dioxide (CO2) 19 and venous potential hydrogen (pH) 7.34. 

Additional orders were placed for amoxicillin, azithromycin, and ibuprofen, and the patient was admitted for further management of pneumonia with asthma exacerbation. Admission orders included intravenous fluids at half maintenance, regular diet, ceftriaxone, albuterol every three hours, and enteral steroids every twelve hours. 

The patient remained stable on room air, tolerating his diet, with ongoing dry cough. He spiked a fever, treated with antipyretics with resolution. By day three, the patient was back to baseline activity and was afebrile. He was deemed stable for discharge home to complete a course of Augmentin and Prelone, with albuterol every four hours, and close outpatient follow-up.

No, the proposed treatment was not medically necessary.  The patient did not require acute inpatient admission.
Pneumonia occurs because of inflammation of lung tissue from either infectious or non-infectious causes. Infectious causes include bacteria, viruses, and fungi. Non-infectious causes include aspiration, hypersensitivity reactions, and drug- or radiation-induced pneumonitis. Streptococcal pneumoniae is the most common bacterial pathogen of infants and young children, while Mycoplasma pneumoniae and Chlamydophile pneumoniae are the most common bacterial pathogens of children and adolescents. Other bacterial agents include Streptococcus pyogenes and Staphylococcus aureus. Viral pathogens include respiratory syncytial virus (RSV) and influenza, as well as rhinovirus, human metapneumovirus, parainfluenza, and adenovirus. Bacterial pneumonia typically occurs when organisms from the respiratory tract colonize the trachea and then gain access to the lungs, although hematogenous spread is also possible. Different bacterial pathogens invade according to their own specific pathogenic processes. Viral pneumonia occurs from viral spread along the airways accompanied by direct injury to the tissues with subsequent airway obstruction. Clinically, pneumonia is typically preceded by upper respiratory tract infection symptoms, including cough and runny nose. The type and degree of symptoms of lower respiratory tract infection depend upon the organisms and stage of illness. 

Tachypnea, fever, cough, and chest pain may all be present. Physical examination findings may include decreased breath sounds, crackles, tachypnea, and shortness of breath. Infiltrate on chest x-ray is supportive of the diagnosis and may be accompanied by effusion. There may be laboratory indicators of infection, including leukocytosis and elevated inflammatory markers. Treatment is based on the suspected cause. Hospitalization may be warranted in the very young, patients with concurrent serious chronic medical conditions, moderate to severe respiratory distress, need for supplemental oxygen, dehydration, inadequate response to outpatient therapy, and complications such as empyema, abscess, or sepsis.

This young child with medical history significant for intermittent asthma and prior pediatric intensive care unit (PICU) admission presented with persistent cough, increasing respiratory distress, wheezing, and fever. Chest x-ray revealed infiltrate suggestive of pneumonia. He was treated with bronchodilators in the emergency department (ED) as well as antipyretics and admitted for further care. While it was not unreasonable to continue providing aggressive respiratory treatment in the hospital setting, particularly given his history of pediatric intensive care unit (PICU) admission, he was overall stable with no oxygen requirement, no evidence of impending respiratory failure, and no significant respiratory distress. The patient did not require acute inpatient admission and could have been safely managed at lower level of care such as observation.

Yes, the health plan acted reasonably.
This child could have been safely managed at lower level of care such as observation.