Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Upper Respiratory Infection

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient is a child with a past medical history of orbital hemangioma and pneumonia that presented to the Emergency Department (ED) complaining of cough, increased work of breathing, non-bloody, non-bilious post-tussive vomiting x 3 days, tactile fever x 1 day, decreased oral intake, and possible decreased urine output. There was no associated measured fever, weight loss, pain, or diarrhea. There were no sick contacts. The patient's vitals were notable for pulse 144, temperature 37.6 Celsius, respiratory rate (RR) 46, blood pressure (BP) 91/60 and room air oxygen saturation of 96%. Physical exam showed an awake and alert child. The patient had moist mucus membranes and normal cap refill. There was nasal crusting. Lungs were notable for inspiratory/expiratory wheezing and intercostal retractions. Cardiac exam was unremarkable. Abdomen exam was soft and flat. There was no associated pain, organomegaly, distension, rebound, guarding or masses. There was no rectal exam reported. Admitting laboratories were notable for sodium 137, potassium 3.4, bicarbonate 15, blood urea nitrogen (BUN) 13, creatinine 0.53, glucose 148, white blood cell count 15.1 with left shift (neutrophils 92%, no bands), hemoglobin 12.5 and platelets 310. Respiratory viral panel was negative for influenza A/B, respiratory syncytial virus (RSV) and Covid-19. Rapid strep test was negative. No urinalysis was submitted for review. The patient's admitting weight was 15.8 kilograms. The patient was treated with 3 Combivent nebulizer treatments as well as dexamethasone intravenously x 1 at 10:37. In addition, the patient received one 316 milliliters (ml) bolus of normal saline followed by dextrose 5% (D5) normal saline at 52 ml/hour. The patient was given oral Zofran. A chest x-ray showed bilateral perihilar and parabronchial thickening suggestive of viral bronchiolitis. 

This child appears to have a viral upper respiratory tract infection with post-tussive vomiting and minimal dehydration. Although intake was overall decreased, the patient was never significantly dehydrated and was already tolerating oral rehydration. 
 
The documentation of this child's appearance (moist mucus membranes and normal cap refill) and vitals/weight change during the admission (actually dropped from 15.8 -> 15.2 kilograms with intravenous hydration) would indicate minimal to no dehydration on presentation that resolved prior to the decision to admit. The modest fluid resuscitation and oral Zofran in the Emergency Department had achieved resolution of vomiting prior to the decision to prematurely admit to the inpatient setting occurred. Intravenous fluids with/without the oral Zofran would have been enough to permit adequate oral rehydration as per standard of care. The patient appeared to be admitted for observation and supplemental intravenous fluids despite having no significant dehydration. This patient actually never received any acute care after admission to the inpatient setting to merit reimbursement at this level. The suggestion in the appeal that their respiratory symptoms persisted after admission was inaccurate as resolution of respiratory distress without additional treatments was stated repeatedly in the progress notes. In regard to the acute inpatient admission, the determination by the carrier that the admission was not medically necessary was correctly applied, objective, clinical valid, compatible with established principles of health care and flexible enough to permit justified variation.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.