Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory syncytial virus bronchiolitis
Treatment: Inpatient emergency admission
The insurer denied an inpatient emergency admission.
The determination is upheld.


The patient presented to the emergency department (ED) with a five-day history of a cough and congestion. He had been seen in the ED the day prior for difficulty breathing, and was given nebulized normal saline, and discharged home. He returned with tachypnea and wheezing. He was eating at baseline, with no fevers or other constitutional symptoms. Vital signs included a temperature of 37.1 degrees Celsius, heart rate 137, and respiratory rate 40 with 100% saturation in room air.

The examination was significant for no acute distress, non-toxic appearance, moist mucous membranes, mild respiratory distress with increased work of breathing, subcostal and intercostal retractions, end-expiratory wheezing, and non-focal neurologic exam. He was given a trial of albuterol followed by DuoNebs and Decadron. Laboratory evaluation was significant for mild metabolic acidosis (carbon dioxide (CO2) 20), viral panel positive for respiratory syncytial virus (RSV), and relatively unremarkable complete blood count (CBC). A chest x-ray was suggestive of viral pneumonia versus hyperactive airway disease. He was admitted for monitoring and further management of RSV bronchiolitis. Admission orders included albuterol every two hours, nebulized saline every three hours, Decadron, and isolation. The following day, his family reported that he was doing a lot better. Albuterol was weaned to every three hours. By hospital day two, he was doing well with no respiratory distress, tolerating albuterol every four to six hours and stable for discharge home. At issue is the medical necessity of an inpatient admission.

The requested inpatient emergency admission was not medically necessary. He could have been safely managed at a lower level of care.
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 the presence of RSV, laboratory investigation is not typically necessary. In young infants, however, a urinary tract infection may accompany RSV infection, so in a febrile infant, urine studies are warranted. A chest x-ray is usually only necessary in the presence of a 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. However, if the child is considered to be at risk for atopic disease or exacerbation either by personal or family history, a trial of bronchodilator treatment is a reasonable course of action. For those that respond, an asthma pathway may provide significant benefit including steroids in addition to the bronchodilators. Hypertonic saline may be considered to facilitate mucociliary clearance. Antibacterial agents should only be used if there is a concomitant bacterial infection. Finally, hydration via enteral feedings and/or intravenous (IV) fluid is necessary.
This young male presented to the ED with signs and symptoms consistent with RSV bronchiolitis. He responded well to bronchodilators in the ED after all other treatments had failed. He was subsequently admitted for ongoing care and bronchodilator treatment. The infant was able to wean off the bronchodilators relatively rapidly, was able to tolerate a full oral diet, and remained hemodynamically stable. At no time was there concern for decompensation or severity of illness. He did not require acute inpatient admission and could have been safely managed at a lower level of care.