Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  RSV (respiratory syncytial virus) Bronchiolitis.
Treatment:  Inpatient stay.
The health plan denied the inpatient stay.  
The denial is upheld.

This is a female infant, fully vaccinated, who presented to the emergency department (ED) with a two-day history of a cough, rhinorrhea, and fever to 101.2 degrees Fahrenheit (F), treated with Tylenol. She was feeding well and voiding at baseline. Of note, her family history is significant for asthma in her mother. Examination was significant for non-toxic appearance, tachypnea with retractions in mild respiratory distress, moist mucous membranes, benign abdomen, clear lungs, and non-focal neurologic exam. Rapid viral testing yielded respiratory syncytial virus (RSV) positive. She was treated with Tylenol for temperature spike to over 101. On re-evaluation, she was tachypneic with retractions. She appeared comfortable without hypoxia. The temperature had fallen to 100.5 degrees F (Fahrenheit). She was diagnosed with RSV bronchiolitis and admitted to the pediatric floor for monitoring and supportive care. Admission orders included regular diet for age, single dose of enteral prednisone, Tylenol as needed for fever, continuous pulse oximetry, and nasal suctioning as needed. She slept well overnight with no observed difficulty breathing. She continued to have mild retractions and some congestion but was otherwise feeding well. An infectious disease consultation was obtained, in agreement with the management. She was deemed stable for discharge to follow-up with her pediatrician within 48 hours. At issue is the medical necessity of an inpatient admission.

No. An inpatient stay 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, diffuse bilateral crackles, generally affecting infants less than 12-24 months of age. The most common causative agent is respiratory syncytial virus, 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.

This term female infant with family history of asthma presented with increased work of breathing and fever secondary to RSV bronchiolitis. She was monitored in the emergency department following Tylenol. She had persistent tachypnea and retractions even though temperature had decreased. She was admitted for ongoing monitoring and supportive care. She did well overnight with resolution of respiratory distress, no fevers, and no oxygen requirement. While it was not unreasonable to monitor her in the hospital overnight for worsening of symptoms versus improvement, she was overall hemodynamically stable with no evidence of impending respiratory failure and no need for supplemental oxygen. She did not require acute inpatient admission and could have been safely managed at a lower level of care.