Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nasal Congestion and Rapid Breathing
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is overturned.

The patient is a male infant with history of bronchiolitis (two episodes, including a pediatric intensive care unit [PICU] admission) and daily wheezing treated with routine budesonide and albuterol as needed at home, as well as family history of asthma. The patient presented to the emergency department with one-day history of cough, same-day history of increased work of breathing (belly breathing, nasal flaring, grunting), 
decreased feeding, and worsening congestion. Frequent suctioning and albuterol every two hours were only somewhat beneficial.

The patient's vital signs included temperature 37, heart rate 148, respiratory rate 46, and saturation 98% (percent) in room air. Examination was significant for no acute distress, non-toxic appearing, happy making loud laughing noises, congestion, moist mucous membranes, tachycardia, clear lungs, benign abdomen, no rashes, and non-focal neurologic exam. There was mild desaturation noted while feeding. Labs were obtained, with unremarkable metabolic panel and negative rapid viral testing. Respiratory panel was pending. The patient was treated with albuterol and dexamethasone with no benefit. He began treatment with high flow nasal cannula (HFNC) at eight liters per minute with fraction of inspired oxygen (FiO2) 0.30, was placed on intravenous fluids, and was admitted for further management. 

Admission orders included placing the patient on the HFNC bronchiolitis pathway, suctioning as needed, hold feedings if worsening tachypnea with intravenous fluids while nothing per mouth (NPO), continuous pulse oximetry while receiving supplemental oxygen, continue home medications, trial albuterol as needed. In addition, Pulmonology was consulted, and the respiratory viral panel returned positive for rhinovirus-enterovirus. Pulmonology recommendations included increasing the dosage of budesonide. The patient was evaluated by Speech and Language Pathology for possible aspiration, and his mother was educated on feeding with suctioning prior. Both Pulmonology and Speech and Language Pathology recommended outpatient follow-up. The patient was able to wean from HFNC and supplemental oxygen and was deemed stable for discharge on day # (number) 2. The patient was formally diagnosed with mild persistent asthma with acute exacerbation.

The proposed inpatient hospital admission was medically necessary.

This male infant with medical history of significant respiratory issues including PICU admission and routine treatment with inhaled steroids and frequent bronchodilator treatments even when healthy presented with signs and symptoms consistent with bronchiolitis. He did not initially respond to bronchodilators, at home or in the emergency department, but he did well with HFNC and supplemental oxygen with aggressive suctioning. He was admitted for ongoing care. Although the patient was hemodynamically stable upon admission, he was experiencing his third bout of wheezing with respiratory distress following viral infection and this time it was quite severe with grunting and nasal flaring. In addition, his baseline included routine wheezing. He was ultimately diagnosed with persistent asthma during this admission.

The level of care that the patient required to determine optimal course of treatment, and the monitoring to see if he would experience continued deterioration or begin to show improvement, was most consistent with acute inpatient level of care. The hospital stay was medically necessary at acute inpatient level of care; a lower level of care would not have been sufficient or appropriate.