Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cough, runny nose.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is overturned. The inpatient admission was medically necessary. 

The patient is a female child with medical history significant for two recent admissions to the hospital for dehydration and increased work of breathing associated with viral illness, the most recent less than a month prior to this presentation.  She presented to the ED with three-day history significant for non-productive cough and runny nose.  She was treated with nebulized saline with improvement.  She had continued cough unresponsive to albuterol every four hours, and then spiked a fever to 101.2.  On the day of presentation, she awoke with increased work of breathing and retractions.  She was taken to the ED after failure of home nebulized treatments.  She was not drinking, and she had decreased urine output. 

The patient's vital signs included temperature 36.6, heart rate 172, respiratory rate 36, and 93% saturation in room air.  Examination was significant for suprasternal retractions and coarse breath sounds.  The differential diagnosis included reactive airway disease and bronchiolitis.  She was treated with two CombiNebs, albuterol every two hours, prednisolone that she vomited followed by Solumedrol, and a normal saline bolus followed by maintenance IV fluids.  She was admitted because of persistent signs of respiratory distress despite ED management.  The patient continued to receive albuterol every two hours following admission, slowly weaning to every three hours and then to every four hours.  IV fluids were discontinued once she was drinking well and making wet diapers.  She was deemed stable for discharge home with diagnosis of bronchiolitis to follow-up with Pediatric Allergy because of recurrent wheezing and strong family history of asthma. 

Bronchiolitis is an inflammatory process that affects predominantly small airways. . . . Treatment is generally supportive, including hydration, supplemental oxygen, and assisted ventilation when necessary (CPAP [continuous positive airway pressure], 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 IV fluids is necessary. 

This young child with recent hospitalization for bronchiolitis and strong family history presented to the ED with increased work of breathing and bronchospasm.  She was initially treated as an asthmatic with albuterol and corticosteroids.  She was ultimately diagnosed with bronchiolitis, but still with a strong family history.  Given the recent hospitalization for bronchiolitis, failed treatment at home with albuterol every four hours, and persistent distress in the ED despite aggressive management with albuterol and steroids and fluids, it was medically appropriate to admit as an acute inpatient despite the relatively short hospital stay.