Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Difficulty breathing. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission.  The denial is overturned. 

The patient is a male. At the time of admission, the infant patient with a medical history significant for an episode of bronchiolitis two months prior that required PICU (pediatric intensive care unit) management for high flow oxygen. He presented to the ED (emergency department) with three-day history of runny nose and congestion and a one-day history of difficulty breathing. The family contacted his pulmonologist with recommendations to treat with steroids and albuterol with no significant benefit. No fever was reported, but the patient had multiple episodes of vomiting. 

In the ED (emergency department), the patient was noted to have significantly increased work of breathing with wheezing, nasal flaring, and suprasternal retractions. A venous blood gas was unremarkable, but lactate was elevated at 2.5 and CO2 (carbon dioxide) was low at 21. Respiratory viral panel was positive for enterovirus/rhinovirus. 

The patient was treated with a normal saline bolus and ceftriaxone, placed on IV (intravenous) fluids with nothing by mouth, and started on high flow nasal cannula (HFNC) at 19L (liters) and FiO2 (fractional inspired oxygen concentration) 0.24. 

The patient was admitted to the PICU (pediatric intensive care unit) for further management. Admission orders included maintenance IV (intravenous) fluids, parenteral steroids, famotidine, and albuterol every two hours. The HFNC (high flow nasal cannula) was titrated as tolerated to 10L (liters) with FiO2 (fractional inspired oxygen concentration) 0.35. The following day, the HFNC (high flow nasal cannula) was weaned further to 8L (liters), and his diet was advance to full liquid diet. He remained clinically symptomatic with intermittent tachypnea and coarse crackles. He remained on bronchodilators and was slowly weaned to room air. 

The patient was significantly improved, tolerating oral feedings and oral medications. He was deemed stable for discharge, to complete a course of steroids and follow-up with both his pediatrician and his pulmonologist. 

Yes, the Inpatient admission was 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 to 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. 

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 inability to feed. Other than confirmatory testing for presence of RSV (respiratory syncytial virus) (or other common respiratory viruses), laboratory investigation is not typically necessary. In young infants, however, urinary tract infection may accompany RSV (respiratory syncytial virus) infection, so in a febrile infant, urine studies are warranted. 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, retractions; hypoxia, with saturations less than 90 to 92%; poor feeding or dehydration; cyanosis; 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 (CPAP [continuous positive airway pressure], high flow nasal cannula oxygen, mechanical ventilation). 

In this case, the infant required assisted ventilation with high flow nasal cannula oxygen as well as IV (intravenous) fluids. He was able to wean from both over the course of his hospital stay. The care that he received was most consistent with acute inpatient management. He could not have been safely or appropriately managed at a lower level of care, or in the outpatient setting.