Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gasping for air/Bronchiolitis.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female child with a medical history significant for hemoglobin C (HbC) trait who presented to the Emergency Department with three separate episodes of gasping for air. She had one episode in the late morning lasting several seconds, and a second episode in the early afternoon. She was taken to urgent care where she had the third episode as the family was leaving. She was transferred to the Emergency Department for further evaluation. 

None of the spells were associated with apnea or color change. She had upper respiratory infection (URI) symptoms and a low-grade fever (100.5 rectal in urgent care) but was otherwise breastfeeding well with good urine output. Vital signs included a heart rate of 141 and a respiratory rate of 76 with 100% saturation on room air. The examination was significant for non-toxic appearance, congestion, moist mucous membranes, tachypnea, no accessory muscle usage, normal breath sounds, and a non-focal neurologic exam. 

Given the patient's desaturation to the low 80s, she was placed on supplemental oxygen. She was noted to have retractions while in the Emergency Department. Laboratory evaluation revealed a normal white blood cell (WBC) count of 15.0K, anemia with a hemoglobin of 8.9, thrombocytosis with platelets of 561K, and negative urinalysis. Electrocardiogram was unremarkable for age. Chest x-ray revealed left upper lobe opacity, atelectasis versus pneumonia, as well as perihilar interstitial opacities and peri-bronchial thickening. She was admitted for further care of probable bronchiolitis with a low level of suspicion for serious bacterial infection. Admission orders included cardiopulmonary monitoring, consideration for antibiotics due to opacity on chest x-ray, four-limb blood pressures, saline as needed, ad-lib feeds, and supplemental oxygen as needed to maintain saturations greater than 90%. A respiratory pathogen panel was obtained and was negative. She did well without further desaturations, no need for supplemental oxygen, and no fevers. She was deemed stable for discharge to follow-up with her pediatrician.

No, the proposed inpatient admission was not medically necessary.

Bronchiolitis is an inflammatory process that affects predominantly small airways. Acute bronchiolitis is a clinical diagnosis given to the following constellation of signs and symptoms: viral upper respiratory prodrome followed by increased respiratory effort, wheezing, and diffuse bilateral crackles, generally affecting infants less than 12-24 months of age. The most common causative agent is a respiratory syncytial virus (RSV), but other viruses can cause bronchiolitis as well, including adenovirus, rhinovirus, influenza, enterovirus, parainfluenza, and human metapneumovirus. Non-viral causes include mycoplasma, chlamydia, fungi, and mycobacteria. Bronchiolitis typically starts in the upper airways and spreads to the lower airways within a few days, resulting in inflammation, edema, mucous production, and bronchospasm. Infants with bronchiolitis usually present with tachypnea, tachycardia, and prolonged expiratory phase. High fever is uncommon. 

On examination, there may be signs of respiratory distress, including wheezing, nasal flaring, retractions, and tachypnea. If there is significant congestion, infants may exhibit signs of dehydration from an inability to feed. Other than confirmatory testing for the presence of RSV (or another viral pathogen), laboratory investigation is not typically necessary. A chest x-ray is usually only necessary in the presence of significant fever, hypoxia, or underlying cardiopulmonary disease. A conservative approach to management is generally appropriate, particularly for the very young in whom apnea must be a consideration. Indications for hospitalization vary from institution to institution and practitioner to practitioner with quite a bit of debate, but typically include the following: moderate to severe respiratory distress, including nasal flaring, tachypnea, and retractions; hypoxia, with saturations less than 90-92%; poor feeding or dehydration; cyanosis; the history of apnea; infants that are considered high risk either by very young age or underlying medical condition; poor social situation; severe malnutrition; and uncertainty over the diagnosis. 

Treatment is generally supportive, including hydration, supplemental oxygen, and assisted ventilation when necessary (continuous positive airway pressure [CPAP], high flow nasal cannula oxygen, mechanical ventilation). The current recommendation is not to use bronchodilator medications, including epinephrine and albuterol, because studies have failed to show sustained benefit. Hypertonic saline may be considered to facilitate mucociliary clearance. There is no place for corticosteroid administration because the evidence has shown no benefit when used alone, and only tentative benefit when used in conjunction with bronchodilators. Use of supplemental oxygen is at the clinician's discretion, particularly if oxygen saturation as measured by pulse oximetry is greater than 90%. There is no evidence to suggest that the application of supplemental oxygen for saturation above 90% adds any benefit and may, in fact, prolong the hospital stay. For this reason, continuous pulse oximetry is not considered standard. Antibacterial agents should only be used if there is a concomitant bacterial infection. Finally, hydration via enteral feedings and/or intravenous (IV) fluids are necessary.

This child presented as a young infant with three separate and distinct gasping episodes. She arrived late in the day and underwent a partial septic workup in the Emergency Department. She was admitted for monitoring. Her admission history/physical was made. She was briefly on supplemental oxygen because of desaturation to the low 80s but thereafter remained stable on room air. While it was not unreasonable to monitor the patient in the hospital for up to 24 hours, she was overall hemodynamically stable, with no evidence of impending respiratory failure and no signs of sepsis or significant dehydration. She did not require acute inpatient admission and could have been safely managed at a lower level of care, such as observation.