Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Viral Infection
Treatment: Inpatient emergency admission
The health plan denied: Inpatient emergency admission
The determination is: Upheld

The patient is a male infant that was taken to the emergency department (ED) with three-day history of cough, two-day history of fever, and one-day history of fast breathing, as well as family history of asthma (sister, father, grandmother). He had been taken to his pediatrician where he was diagnosed with a viral upper respiratory infection (URI) and prescribed nebulized saline. He was treated with nebulized normal saline every four hours without improvement. His intake was reportedly fair with good urine output. His vital signs included a temperature of 39.5 Celsius, a heart rate of 182 beats per minute (bpm), a respiratory rate of 38/minute, with 100 percent (%) saturation in room air. The examination was significant for alert appearance, nasal congestion, moist oral mucosa, good air entry bilaterally, suprasternal and subcostal retractions, benign abdomen, and non-focal neurologic exam. Rapid viral testing was negative. He was treated with nebulized saline and a dose of acetaminophen, after which the decision was made to admit to the hospital for further management of acute bronchiolitis. Admission orders included continuous cardiopulmonary monitoring, formula ad lib every three hours, nebulized saline every three hours, and Tylenol as needed. A urinalysis was obtained and was concentrated and positive only for 1+ protein and 6-10 white blood cells (WBC). He did well, with improving work of breathing, no need for supplemental oxygen, and was feeding well with good urine output. He was deemed stable for discharge, with nasal saline drops every six hours as needed and close outpatient follow-up.
At issue is the medical necessity of the inpatient emergency admission.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of inpatient emergency admission was not medically necessary for this patient.
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 (RSV), 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.
This young male infant was taken to the ED with signs and symptoms consistent with viral URI progressing to bronchiolitis. He was still feeding adequately and making wet diapers. Because of his age and the progression of his symptoms, it was reasonable to monitor him in the hospital. However, he was hemodynamically stable, with no significant dehydration and no need for supplemental oxygen. He did not require acute inpatient admission and could have been safely managed at an alternate level of care.