Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System-Respiratory Syncytial Virus/RSV
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

This is a pediatric patient at the time of presentation, presenting for low oxygen saturation at the primary medical doctors (PMDs) office in the setting of 5 days of cough and nasal congestion as well as fever x (times) 1 day. The grandmother took the patient to the PMD where she was told that the patient appeared to have respiratory syncytial virus (RSV) bronchiolitis. However, patient did not have a fever and was not breathing heavily so PMD recommended steam baths, saline nose drops, and bulb suction as needed (PRN). Initial temperature was 99 Fahrenheit (F) and subsequent check was 103F rectal. Mother gave Tylenol for the fever and took the patient to the PMD. At the office the patient was noted to have low oxygen (less than 90) and the patient's color was not good. PMD recommended that the patient go to the emergency room (ER). Respiratory viral panel (RVP) at the office was RSV positive. Associated symptoms included decreased by mouth (PO) intake. ER temperature was 98.9 rectal, heart rate (HR) 158, respiratory rate (RR) 34, oxygen (O2) saturation was 100% (per cent) on room air. Patient had mild suprasternal retractions. He received 1 bolus of intravenous fluids (IVF). Labs revealed a white blood cell count (WBC) 14, neutrophils 36, bands of 7. The basic metabolic panel (BMP) with sodium (Na) 134, potassium (K) 5.3. A venous blood gas (VBG) revealed a potential hydrogen (pH) 7.404, carbon dioxide (CO2) 39.3, and O2 48.3. RVP confirmed the patient is RSV positive. Patient had an episode of O2 desaturation to 85% so was placed on 2.5Liters via nasal cannula (NC) for one hour. Patient clinically improved and remained asymptomatic,  and was discharged home. 

The requested health service/treatment of inpatient stay was medically necessary for this patient. This neonate presented with RSV bronchiolitis and an episode of hypoxia with poor color witnessed by his pediatrician. In the ER he did have some suprasternal retractions. It is well known that RSV can cause apnea and/or respiratory failure in neonates. Patient was admitted and monitored closely for signs of deterioration. He had an episode of hypoxia down to 85% requiring supplemental oxygen. Given this child's age and his progression to hypoxia, he would need very close monitoring, such as frequent respiratory assessments, and increased level of care to ensure he does not progress into respiratory failure. It has been noted that oxygen saturation is the most consistent clinical predictor of deterioration. Based on the literature, the patient met two clinical criteria that are strong predictors of clinical deterioration and possible need for major intervention. The infant exhibited hypoxia with an oxygen requirement and age of less than 12 months. Even though the child appeared stable at the time of admission, with neonates, their clinical status, when infected with RSV, can quickly change and deteriorate. They are at risk for apnea and respiratory failure. Continuous pulse oximetry and frequent respiratory assessment would be needed to monitor his clinical status especially given the fact that he required supplemental O2 to maintain his saturations at one point.