Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bronchiolitis
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a male child with unremarkable medical history. He presented to the ED (emergency department) with four-day history of worsening cough, runny nose, nasal congestion, and decreased intake. He also had fevers to 104.1 degrees F (Fahrenheit). He was originally taken to the ED, w here he was diagnosed with RSV (respiratory syncytial virus) and non-COVID coronavirus infection. He was discharged from the ED with an albuterol inhaler to use every four to six hours. Despite proper administration of the medication, he was persistently febrile with productive cough and tachypnea. Additional symptoms included ongoing decrease appetite and decreased urine output.

In the ED, the patient's vital signs included temperature 98.3, heart rate 143, respiratory rate 30. Examination was significant for well-hydrated appearance, tachypnea without retractions, non-toxic appearance, no nasal discharge, tacky moral mucosa, no pharyngeal exudate or inflammation, non-productive cough, non-focal neurologic exam. Interventions included Tylenol, albuterol, an oral challenge, and reassessment. He was noted to by hypoxic to 88% (percent) when asleep, increased to 96% with supplemental oxygen.

The patient was treated with an IV (intravenous) fluid bolus and admitted to the Pediatric floor for management of acute bronchiolitis and dehydration. Admission orders included antipyretics, IV fluids at maintenance, and supportive care. He was noted to have increased work of breathing during sleep, so remained on nasal cannula oxygen. His appetite was still poor. Laboratory evaluation revealed WBC (white blood cell) count 13.6K (thousand) with 40% neutrophils, BioFire positive for RSV, and unremarkable metabolic panel. His supplemental oxygen was weaned, and upon re-evaluation continued to have some scattered mild wheezes but was overall stable. He was treated with albuterol, spacing treatments to every three hours. Chest x-ray was completed due to worsening cough, positive for infiltrate and pneumonia. He was started on Unasyn to treat community-acquired pneumonia. Albuterol was further spaced to every four hours.

The patient's appetite had improved significantly. He was afebrile, systemic steroids had been added with a dose increase, and was deemed well enough to discharge home.

No, the inpatient hospital admission was not medically necessary.

The patient could have been safely managed at lower level of care.

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.

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, laboratory investigation is not typically necessary. In young infants, however, urinary tract infection may accompany RSV 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 90-92%, 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). The current recommendation is not to use bronchodilator medications including epinephrine and albuterol because studies have failed to show sustained benefit. However, if the child is considered to be at risk for atopic disease or exacerbation either by personal or family history, a trial of bronchodilator treatment is a reasonable course of action. For those that respond, an asthma pathway may provide significant benefit including steroids in addition to the bronchodilators. Hypertonic saline may be considered to facilitate mucociliary clearance. Antibacterial agents should only be used if there is a concomitant bacterial infection. Finally, hydration via enteral feedings and/or IV fluids is necessary.

This young male child with no significant atopic history but previous episode of reactive airway disease (RAD) presented with known RSV infection and worsening respiratory symptoms. He was hypoxic during sleep necessitating treatment with supplemental oxygen. His appetite was poor. He was admitted initially for management of bronchiolitis with potential RAD exacerbation, but was diagnosed during the hospitalization with pneumonia and started on parenteral antibiotics. He was subsequently discharged home. While it was reasonable and appropriate to monitor him in the hospital for improvement versus deterioration, he was overall hemodynamically stable with no evidence of impending respiratory failure, no severe dehydration or bronchospasm. He did not require acute inpatient admission and could have been safely and appropriately managed at a lower level of care, such as observation.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.