Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath and cough
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 reactive airway disease that presented to the ED with several-day history of cough and cold-like symptoms and one-day history of acute worsening with shortness of breath and cough. There was no fever. He was given nebulized albuterol every four hours without resolution. 

Vital signs included temperature 37.0, heart rate 144, respiratory rate 26, and 96% oxygen saturation in room air. Physical examination was significant for respiratory distress, wheezing, tachypnea, and non-focal neurologic exam. Laboratory evaluation was significant for white blood cell (WBC) count 13.3K with 93.1% neutrophils, borderline metabolic acidosis with carbon dioxide (CO2) 20, negative rapid influenza and respiratory syncytial virus (RSV), hyperglycemia with glucose 216, and negative urinalysis. He was treated with one DuoNeb, parenteral steroids, and normal saline bolus. Following the breathing treatment, his lungs were clear and he was sleeping. Chest x-ray revealed bilateral pneumonia. The patient was re-evaluated and was found to have mild wheezing with mild retractions. He was treated with ceftriaxone and arrangements were made for admission to the pediatric ward. Admission orders included regular diet for age, intravenous (IV) fluids, anti-pyretics, parenteral steroids, ceftriaxone, and albuterol and Atrovent treatments. The following day, he was found to have no respiratory distress, with scattered wheezing and rhonchi in both lungs. He continued on antibiotics and breathing treatments. Repeat bedside glucose was 169. He was subsequently deemed stable for discharge, to complete a course of azithromycin and prednisolone, and follow-up with his pediatrician in two days. Additional discharge instructions included repeat chest x-ray in one month, Pulmonology consultation, and Immunology consultation.   

Pneumonia occurs as a result of inflammation of lung tissue from either infectious or non-infectious causes. Infectious causes include bacteria, viruses, and fungi. Non-infectious causes include aspiration, hypersensitivity reactions, and drug- or radiation-induced pneumonitis. Streptococcal pneumoniae is the most common bacterial pathogen of infants and young children, while Mycoplasma pneumoniae and Chlamydophile pneumoniae are the most common bacterial pathogens of children and adolescents. Other bacterial agents include Streptococcus pyogenes and Staphylococcus aureus. Viral pathogens include RSV and influenza, as well as rhinovirus, human metapneumovirus, parainfluenza, and adenovirus. Bacterial pneumonia typically occurs when organisms from the respiratory tract colonize the trachea and then gain access to the lungs, although hematogenous spread is also possible. Different bacterial pathogens invade according to their own specific pathogenic processes. Viral pneumonia occurs from viral spread along the airways accompanied by direct injury to the tissues with subsequent airway obstruction. Clinically, pneumonia is typically preceded by upper respiratory tract infection symptoms, including cough and runny nose. The type and degree of symptoms of lower respiratory tract infection depend upon the organisms and stage of illness.
 
Tachypnea, fever, cough, and chest pain may all be present. Physical examination findings may include decreased breath sounds, crackles, tachypnea, and shortness of breath. Infiltrate on chest x-ray is supportive of the diagnosis, and may be accompanied by effusion. There may be laboratory indicators of infection, including leukocytosis and elevated inflammatory markers. Treatment is based on the suspected cause. Hospitalization may be warranted in the very young, patients with concurrent serious chronic medical conditions, moderate to severe respiratory distress, need for supplemental oxygen, dehydration, inadequate response to outpatient therapy, and complications such as empyema, abscess, or sepsis.

This young child presented to the ED with signs and symptoms consistent with lower respiratory tract infection and reactive airways disease. He responded well to a breathing treatment in the ED, but on chest x-ray was found to have bilateral infiltrates prompting admission for parenteral antibiotic therapy. While it was not unreasonable to monitor the child for potential decompensation, he was overall hemodynamically stable, with no oxygen requirement, no evidence of sepsis, no evidence of impending respiratory failure, and no significant dehydration. He did not require acute inpatient admission and could have been safely managed at a lower level of care.