Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Difficulty breathing
Treatment: Hospital admission
The insurer denied the hospital admission.
The denial is overturned.

The patient is a male who presented to the emergency department with difficulty breathing. He was well until 2 days prior to presentation when he developed cold symptoms and fever up to 100.5 Fahrenheit (F). The day prior to presentation he had difficulty breathing as well as body aches and chills. He received a dose of albuterol at home with limited response. He then spit up phlegm with streaks of blood, and therefore was brought to the emergency department for evaluation.

In the emergency department he was found to have a temperature of 99.3 F and was wheezing bilaterally with tachypnea and an oxygen saturation of 92%. He was given dexamethasone, magnesium sulfate, and 3 albuterol/Atrovent nebulized treatments. He also required supplemental oxygen, with 2 liters by nasal cannula. Laboratory values were obtained which revealed a white blood count of 21 with a left shift. A viral panel was positive for entero/rhinovirus. A chest x-ray revealed bilateral perihilar infiltrates. He was subsequently admitted to the hospital for management of viral bronchiolitis with pneumonia.

Upon admission he continued to wheeze and was in mild to moderate respiratory distress. He was treated with Ceftriaxone, Azithromycin, and intravenous fluids as well as methylprednisolone and albuterol every 2 hours. He improved over time and was able to wean to every 3 hour and then every 4 hour albuterol treatments. By hospital day #4 he was able to wean to room air. He was then felt to be stable for discharge with follow up as an outpatient.

The subject under review is the medical necessity for the hospital admission.

The health plan's determination is overturned.

The requested hospital admission was medically necessary for this patient. This is a patient who presented with tachypnea and wheezing and was found to have a viral infection and pneumonia. He received appropriate and intensive treatment in the emergency department setting but continued to have wheezing and increased work of breathing. He was also hypoxemic with an oxygen saturation of 92%. He required inpatient hospitalization for treatment with intravenous antibiotics, intravenous fluids to maintain his hydration status, and frequent breathing treatments (initially every 2 hours) as well as supplemental oxygen.

According to the Milliman Care Guidelines, Pediatric, Pneumonia, hospitalization is indicated for patients with retractions, grunting or flaring or with respiratory findings including persistent wheezing and intravenous fluid requirement or other treatment requiring inpatient admission.

This patient had persistent retractions and required intravenous fluids as well as parenteral antibiotics, supplemental oxygen, and frequent bronchodilator therapy. Therefore, inpatient admission was required. A lower level of care would not have been appropriate for this care this patient required.

The decision making at the time of admission for this patient was consistent with his age, the presence of wheezing, respiratory distress, and hypoxemia, and the need for intensive treatments for a viral infection and superimposed pneumonia along with close monitoring for potential deterioration of clinical status.