Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma (difficulty breathing)
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

No, the inpatient admission was not medically necessary.

The patient is a male child with medical history significant for mild persistent asthma that was taken to the ED via EMS with audible "difficulty breathing", gasping for air. He had no fevers or history of foreign body aspiration. He had one episode of vomiting and appeared to be foaming at the mouth with subsequent cyanosis. 

Vital signs included temperature 36.6, heart rate 188, respiratory rate 46, and oxygen saturation 90% in room air. Examination was significant for distressed appearance, clear oropharynx, tachycardia, diaphoresis, nasal flaring, stridor, retractions, and non-focal neurologic exam. He was treated with racemic epinephrine and dexamethasone with significant improvement. While he was being observed in the ED, he had recurrence of stridor at rest (about two hours later) less pronounced than upon presentation. He was given another dose of racemic epinephrine with improvement, and plans were made for admission. Admission orders included regular diet for age and Tylenol as needed. He required no further racemic epinephrine. He had mild coughing, but no stridor at rest or with activity. He was deemed stable for discharge to follow-up with his pediatrician.

Croup, or laryngotracheobronchitis, is a viral infection of the glottis and subglottic regions, and is the most common form of acute upper respiratory obstruction. Typically, patients start with upper respiratory tract infection symptoms, with runny nose, sore throat, cough, and low-grade fever. The "barking" cough then develops, including hoarseness and inspiratory stridor. Low grade fever may persist and may spike to 104. Symptoms are classically worse at night and persist for the better part of a week. Agitation worsens the symptoms. Croup is a clinical diagnosis, although neck radiographs may reveal typical subglottic narrowing ("steeple sign"). Although the differential diagnosis includes epiglottitis, these patients are typically ill in appearance, with drooling and tripod positioning. Sudden onset stridor may represent foreign body aspiration, but there is no evidence of infection. The mainstay of treatment of croup is airway management, with most children managed safely at home. For moderate to severe croup, racemic epinephrine may help to reduce laryngeal mucosal edema. Indication for administration is typically stridor at rest, hypoxia, respiratory distress, and impending need for intubation. Corticosteroids reduce edema through anti-inflammatory action. Oral steroids are beneficial even for mild cases of croup to shorten duration. Antibiotics are typically unnecessary for viral croup. For patients treated with racemic epinephrine, there is typically a period of observation after administration to monitor for recurrence of stridor at rest.  

This young child with history of asthma presented to the ED with signs and symptoms consistent with croup. He was in significant distress but responded well to racemic epinephrine. Two hours after the first dose he had return of symptoms so was given a second dose. He was admitted for monitoring in case he had recurrence of stridor at rest. He did well after admission, with resolution of symptoms and no further stridor. While it was reasonable to monitor him for rebound following the second dose of racemic epinephrine, he was overall stable with no oxygen requirement, no evidence of bronchospasm (asthma exacerbation), no significant dehydration, and no evidence of impending respiratory failure. He did not require acute inpatient admission and could have been safely managed at a lower level of care such as observation.