Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypoxemic Respiratory Failure and Bronchiolitis. 
Treatment: Inpatient admission. 

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

The patient is a male infant born full term that presented to the emergency department (ED) with three-day history of upper respiratory infection (URI) symptoms, two-day history of cough, and one-day history of retractions and difficulty breathing. The patient had no fevers, was not eating well, but was drinking well with good urine output. His sister had nasal congestion. There were no known coronavirus (Covid) exposures. 

Vital signs included temperature 37.7, heart rate 174, respiratory rate 56, and 94% oxygen saturation in room air. Examination was significant for non-toxic appearance, congestion, tachypnea, belly breathing with tracheal tugging, wheezing and wet-sounding cough, good perfusion, and non-focal neurologic exam. Rapid influenza, respiratory syncytial virus (RSV), and coronavirus (Covid) testing were all negative. The patient was treated with nebulized saline with persistent tachypnea, belly breathing, and tracheal tugging. He was placed nothing by mouth with intravenous (IV) fluids and started on high-flow nasal cannula (HFNC) prior to admission for further care. Admission orders included the bronchiolitis clinical pathway, high-flow nasal cannula (HFNC) with eight liters per minute at fraction of inspired oxygen (FiO2) 0.21 (room air) weaning as tolerated, suctioning as needed, nothing by mouth with maintenance intravenous (IV) fluids advancing his diet once his respiratory rate was consistently less than 50, continuous pulse oximetry, and supplemental oxygen as needed to maintain saturations greater than 90%. 

The patient remained stable overnight, with slight weaning in high-flow nasal cannula (HFNC) flow to six liters per minute. He was more comfortable and drinking formula well. He did not require a lot of suctioning. Orders included weaning high-flow nasal cannula (HFNC) as tolerated, weaning intravenous (IV) fluids, and suctioning as needed. The patient continued to improve and was able to wean from high-flow nasal cannula (HFNC) to room air overnight. He remained afebrile and hemodynamically stable with no oxygen requirement for the duration of his hospital stay. He was deemed stable for discharge. 

Yes, the proposed 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 12-24 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 respiratory syncytial virus (RSV), laboratory investigation is not typically necessary. In young infants, however, urinary tract infection may accompany respiratory syncytial virus (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 (continuous positive airway pressure [CPAP], 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. Hypertonic saline may be considered to facilitate mucociliary clearance. There is no place for corticosteroid administration because the evidence has shown no benefit when used alone and only tentative benefit when used in conjunction with bronchodilators. Use of supplemental oxygen is at the clinician's discretion, particularly if oxygen saturation as measured by pulse oximetry is greater than 90%. There is no evidence to suggest that application of supplemental oxygen for saturation above 90% adds any benefit and may in fact prolong hospital stay. For this reason, continuous pulse oximetry is not considered standard. Antibacterial agents should only be used if there is a concomitant bacterial infection. Finally, hydration via enteral feedings and/or intravenous (IV) fluids is necessary. 

In this case, the patient required assisted ventilation with high flow nasal cannula as well as intravenous (IV) fluids. He was able to wean from both over the course of his hospital stay. While he recovered within a couple days, 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. The acute inpatient admission was medically necessary and appropriate for the full duration.