Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COVID 19
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


The patient has a medical history significant for wheezing but no official diagnosis of asthma that was referred to the emergency department (ED) from the doctor's office with low saturation (88-89%) despite three nebulizer treatments as well as retractions. In the office, rapid coronovirus disease (COVID) testing was negative with pending polymerase chain reaction (PCR) and he was given a dose of prednisolone. He had a two-day history of a moist cough, fever to 100.3 degrees, wheezing, and trouble breathing. Vital signs included a temperature of 36 degrees Celsius, heart rate 126, respiratory rate 20, and blood pressure 113/74. The oxygen saturation was 95% on room air.
The examination was significant for a well appearance without acute distress, no pharyngeal erythema, clear lungs, benign abdomen, and non-focal neurologic exam. A chest x-ray was obtained and was negative. COVID testing returned positive. A viral respiratory panel was obtained and was positive for Rhinovirus as well. He was admitted to the pediatric floor for further care. The admitting hospitalist contacted pediatric infectious disease (ID), with recommendations to treat with five days of Remdesivir and parenteral dexamethasone, start deep vein thrombosis (DVT) prophylaxis, and obtain additional lab work including inflammatory markers. Of note, he had COVID previously. Admission orders included the ID recommendations, continuous pulse oximetry, regular diet for age, and routine labs. Laboratory testing was overall unremarkable, including a normal white blood cell count (WBC) count except with left shift 84% neutrophils (possible steroid effect), elevated C-reactive protein (CRP) 31.9. He did well overnight, with normal work of breathing, no oxygen requirement, saturations above 92%. He was deemed stable for discharge home on three days of steroids, the Remdesivir was discontinued, and he was to follow-up with his pediatrician. The entirety of the hospital stay was complete in conjunction with pediatric ID involvement and guidance.
At issue is the medical necessity of an inpatient stay.

The patient did not require acute inpatient management and could have been safely managed at lower level of care.
In early 2020, a world-wide pandemic was declared as a result of COVID-19, a disease caused by a novel Coronavirus, SARS-CoV-2. To date there have been over 254 million cases confirmed world-wide, with over 5 million deaths. There have over 47 million confirmed cases in the United States alone. Since the availability of vaccination, over 7 trillion doses of vaccine have been administered. Since the arrival of the delta variant, cases in children have begun to rise, with almost 6 million children testing positive as of September 23, 2021. Almost half a million cases are added every week at this time. Although COVID-19 has been diagnosed in people of all ages and cases have been rising in children, those at highest risk of severe disease remain older adults and those with severe underlying medical conditions such as cardiopulmonary disease and diabetes. Currently, the risk of COVID-related hospitalization and death in children remains small.
Symptoms may appear from two days to two weeks after exposure, and include the following: fever, chills, cough, shortness of breath, fatigue, body aches, headache, anosmia (loss of smell), sore throat, congestion, nausea, and diarrhea. Complications may occur in any system, and may include adult respiratory distress syndrome (ARDS), encephalopathy, deep vein thrombosis with or without stroke/ pulmonary embolism (PE), myocardial disease, and multisystem inflammatory syndrome in children. Management strategies vary and are updated as new information becomes available. For those with potential exposure, mild or moderate symptoms, symptomatic care and self-quarantining for fourteen days are recommended. Because there are a number of other viral illnesses circulating concurrently, it is prudent to evaluate for such infections using rapid influenza and respiratory syncytial virus (RSV) testing and respiratory viral panels in appropriate circumstances. It is also unclear if one infection confers sufficient immunity to prevent re-infection. There have been a number of patients with resurgence of symptoms and positive testing after recovery with negative testing.
This patient with a history of wheezing and albuterol use and prior COVID 19 infection presented to the pediatrician's office with increased work of breathing refractory to outpatient management. He was sent to the emergency department (ED) for further management and subsequently admitted for management of a COVID 19 infection. He also tested positive for Rhinovirus at that time. He was treated aggressively for COVID per pediatric ID recommendations and also treated for wheezing. He never had an oxygen requirement, his increased work of breathing resolved, and he was able to tolerate his diet. While it was medically necessary and appropriate to observe this child in the hospital for improvement versus decompensation, overall he was hemodynamically stable, with no indication of impending acute respiratory failure, no significant dehydration, and no concerning underlying medical issues that would place him at risk for severe COVID disease. He did not require acute inpatient admission and could have been safely and appropriately managed at a lower level of care while receiving the same interventions.