Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Croup
 
Treatment:  Inpatient Admission

The insurer denied the Inpatient Admission.  The denial was reversed. 
  
This patient is a female child with a medical history of croup prior to presentation. The young patient presented to the emergency room (ER) with complaints of having a croupy cough and difficulty breathing after developing a fever and respiratory infection.  She was noted to have a respiratory rate of 70 with in moderate respiratory distress. Physical exam showed inspiratory stridor and subcostal retraction.  She was treated with 4 doses of dexamethasone, 3 respiratory treatments with racemic epinephrine, and one intramuscular (IM) epinephrine injection.  It was reported that the patient did improve after the treatment but experienced another episode of stridor and was given inhaled Heliox.  A chest x-ray was done with normal results.  Laboratory work up was performed that revealed an elevated lactic acid of 3.9.  The patient was admitted to pediatric intensive care unit (PICU) where she received ongoing Heliox treatments. 

According to UpToDate Croup: Approach to Management, "Croup" (laryngotracheitis) is a respiratory illness characterized by inspiratory stridor, barking cough, and hoarseness.  It typically occurs in children six months to three years of age and is caused by parainfluenza virus.  Respiratory failure - Croup occasionally results in significant upper airway obstruction with impending respiratory failure, heralded by the following signs that include: 1) Fatigue and listlessness, 2) Marked retractions (although retractions may decrease with increased obstruction and decreased air entry), 3) Decreased or absent breath sounds, 4) Depressed level of consciousness, 5) Tachycardia out of proportion to fever, and 6) Cyanosis or pallor.

Pharmacotherapy - the benefits of corticosteroids and nebulized epinephrine for moderate to severe croup have been demonstrated in meta-analysis and randomized controlled trials, respectively.  Specific pharmacologic intervention depends upon the severity of symptoms.  For children with moderate stridor at rest and moderate retractions or more severe symptoms, we recommend administration of dexamethasone (0.6 mg/kg, maximum of 10 mg) by the least invasive route possible: oral if oral intake is tolerated, intravenous if IV access has been established, IM if oral intake is not tolerated and IV access has not been established.  The oral preparation of dexamethasone (1 mg per mL) has a foul taste.  The intravenous preparation is more concentrated (4 mg per mL) and can be given orally mixed with syrup.  A single dose of nebulized budesonide (as described below) is another option, particularly for children who are vomiting.  For children with moderate stridor at rest and moderate retractions, or more severe symptoms, we recommend nebulized epinephrine in addition to dexamethasone.

Indications - Children with moderate/severe croup whose condition worsens or fails to improve as expected after treatment with nebulized epinephrine and corticosteroids should be admitted to the hospital for repeated doses of nebulized epinephrine, observation, and supportive care. Poor response to nebulized epinephrine in conjunction with high fever and toxic appearance should prompt consideration of bacterial tracheitis.
Additional factors that influence the decision regarding admission include: 1) Need for supplemental oxygen, 2) Moderate retractions and tachypnea, indicating increased work of breathing, which may lead to respiratory fatigue and failure, 3) "Toxicity" or clinical picture suggesting serious secondary bacterial infection, 4) Poor oral intake and degree of dehydration, and 5) Recurrent visits to the ED within 24 hours.

The health care plan did not act reasonably and with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital services is substantiated.  The insurer's denial is reversed.