Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever, cough, work of breathing
Treatment: Inpatient admission
The inpatient admission was medically necessary.

The patient is a young female child with history significant for reactive airway disease (RAD) and two pediatric intensive care unit (PICU) admissions for bronchiolitis/RAD requiring high-flow nasal cannula support that presented to the emergency department (ED) with one-day history of fever to 102 unresponsive to Tylenol, cough, congestion, and increased work of breathing. Albuterol at home was ineffective. The child also reported headache and sore throat. 
Vital signs included temperature 37.8, heart rate 184, respiratory rate 38, and 97% saturation in room air. Examination was significant for distressed but non-toxic appearance, moist mucous membranes, clear oropharynx, tachycardia, strong pulses, tachypnea, wheezing, no retractions, benign abdomen, and non-focal neurologic exam. The patient was given two Combineb treatments two hours apart, with the third truncated due to significant tachycardia (heart rate over 200) and shaking. Lab studies were obtained and she was treated with a normal saline bolus and Solu-Medrol. Laboratory evaluation revealed metabolic acidosis (carbon dioxide [CO2] 18), hyperglycemia (221), elevated erythrocyte sedimentation rate (ESR) (30), mildly elevated C-reactive protein (CRP) (1.3), mild leukopenia (white blood count [WBC] 4.6K with normal differential), and negative rapid influenza and positive respiratory syncytial virus (RSV). Her bronchodilator treatments were spaced to every three hours. The patient remained tachypneic, so a chest x-ray was obtained and she was given another normal saline bolus. Chest x-ray revealed bilateral peribronchial cuffing consistent with viral process versus RAD. She was diagnosed with RSV infection with RAD exacerbation and admitted for ongoing bronchodilator treatments every three hours. 
Overnight, bronchodilator treatments were weaned to every four hours. The patient's appetite improved over the course of the hospital stay, her tachycardia resolved, she had no oxygen requirement, and she had no significant fevers. She was deemed stable for discharge to complete a course of enteral steroids and continue nebulized albuterol every four hours as needed.
This patient with history of reactive airway disease and PICU admission for ventilatory support presented to the ED with cough and increased work of breathing. She failed bronchodilator treatment at home. She was unable to tolerate Combineb treatments in the ED every two hours (she was significantly tachycardic, with heart rate over 200, in addition to having tachypnea) so was monitored on treatments with albuterol alone every three hours. She remained tachypneic so was admitted for further respiratory treatments and corticosteroids. Management of this child with RSV infection and increased work of breathing complicated by persistent tachycardia (limiting bronchodilator therapy) and tachypnea necessitated acute inpatient admission. She had failed treatment in the outpatient setting. The acute inpatient hospital admission was medically necessary and appropriate.