Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System. 
Treatment: Inpatient Hospital. 

The insurer denied Inpatient Stay. 
The denial is overturned. 

The patient is a female child with a medical history significant for duodenal atresia status post repair and asthma. She presented to the emergency department (ED) with a ten-day history of respiratory infection. She initially developed symptoms consistent with viral upper respiratory infection that resolved. However, the illness returned with fever to 103, productive cough, decreased appetite, decreased activity, and vomiting associated with cough/fever. Her symptoms continued to worsen, so she was taken to the primary care practitioner, where she was prescribed amoxicillin for possible bacterial infection. She was unable to tolerate the antibiotics by mouth due to recurrent vomiting. Her vital signs included temperature of 39.6, heart rate was 124, respiratory rate was 28 with a 97% saturation on room air, and blood pressure was 98/64. Examination was significant for acute distress, toxic appearance, tachycardia, tachypnea, respiratory distress with retractions but no nasal flaring, rales, no wheezing, mild accessory muscle use, no abdominal findings, brisk capillary refill, and non-focal neurologic exam. 
Her laboratory evaluation revealed leukopenia with a white blood cell count (WBC) at 2.6, metabolic acidosis with carbon dioxide (CO2) at 19, hemoconcentration with hemoglobin at 20.3, mild thrombocytopenia with platelets at 121, and mildly elevated aspartate aminotransferase (AST) at 53. She was treated with a normal saline bolus, Tylenol for the fever, ceftriaxone for possible bacterial infection, and nebulized albuterol, and admitted to the pediatric service for ongoing management of lower respiratory tract infection. 

The chest x-ray was significant for bilateral peribronchial thickening without significant infiltrate. Rapid testing revealed respiratory syncytial virus (RSV) positive. She remained hemodynamically stable, with improving fever curve and no fevers for 36 hours, and adequate oral intake. The repeat complete blood count (CBC) revealed normalization of her WBC count at 5.9 and normalization of hemoglobin at 12.8. She was deemed stable for discharge and to continue Tylenol and saline nasal spray as needed and follow-up with her doctor in two to three days. 

At issue is the medical necessity of Inpatient Stay. 

The health plan's determination of medical necessity is overturned in whole. 

The requested health service/treatment of Inpatient Stay is medically necessary for this patient. 

Acute inpatient admission was medically necessary and appropriate for this young child with failed outpatient management of lower respiratory tract infection secondary to RSV. 
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). 
This young female child with a history of asthma and remote history of duodenal atresia presented with signs and symptoms consistent with lower respiratory tract infection and possible secondary bacterial infection. She had failed outpatient management because she was unable to tolerate oral antibiotics due to vomiting. She was initially admitted for management of possible bacterial infection, but work-up revealed positive RSV, with no significant infiltrate on her chest x-ray and negative blood cultures. Her treatment plan was transitioned to one appropriate for acute RSV bronchiolitis and her symptoms improved sufficiently that she was stable for discharge home. Regardless of the duration of her hospital stay, she had failed outpatient management and with the severity of her presentation (acute distress, toxic appearance, high fever) an acute inpatient admission was medically necessary. 

Therefore, the requested health service/treatment of Inpatient Stay is medically necessary.