Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tachypnea. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

This is a male infant born at term who presented to the emergency department (ED) with tachypnea, a cough, and low-grade temperature elevation (99.7 degrees Fahrenheit). He was drinking well, voiding adequately, with no vomiting or diarrhea. He had been hospitalized several days prior for one day because of vomiting, dehydration, and initial labs concerning for pancytopenia. Repeat labs were unremarkable, he had no further vomiting, and was discharged home. He was taken back to the ED because of sudden onset difficulty breathing with four-day history of cough, low-grade fever, and tachypnea. 

The examination was significant for being active, not ill-appearing, tachypnea, respiratory distress with subcostal retractions, rales, no nasal flaring, and brisk capillary refill. A chest x-ray was obtained. He was treated with a normal saline bolus as well as nebulized normal saline. Following this breathing treatment, he continued to have retractions and the oxygen saturation was dipping down to 92 percent (%). He was treated with nebulized hypertonic saline, still with saturations dipping down to 89%. Laboratory evaluation was significant for thrombocytosis and mildly elevated C-reactive protein (CRP). The chest x-ray was concerning for central peribronchial thickening and interstitial prominence suggestive of viral bronchiolitis. He was admitted for further management of viral bronchiolitis. Admission orders included infant diet for age, cardiopulmonary monitoring, ceftriaxone, nebulized normal saline every three hours, and normal saline nasal drops every three hours. 
Following admission, he was feeding well. He had no further respiratory distress. He was treated with nebulized saline and nasal drops with suctioning every three hours. He had no oxygen requirement. Screening tests for respiratory syncytial virus (RSV), influenza, and coronavirus disease (COVID) were negative. He was deemed stable for discharge. At issue is the medical necessity of an inpatient stay. 

Acute inpatient admission was not medically necessary. Bronchiolitis is an inflammatory process that affects predominantly small airways. Acute bronchiolitis is a clinical diagnosis give 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. A 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 an inability to feed. Other than confirmatory testing for the presence of RSV, laboratory investigation is not typically necessary. 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 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) fluids is necessary.
This infant was taken to the ED for evaluation of increased work of breathing. He had a runny nose and had been coughing for several days. A chest x-ray was consistent with bronchiolitis. His room air saturations dipped below 90% on room air. He was admitted for further management. He did well with nebulized saline and nasal saline drops. While it was not unreasonable to monitor him for improvement versus decompensation, he was overall hemodynamically stable with no need for supplemental oxygen, he was able to drink without difficulty, and his increased work of breathing resolved. He did not require acute inpatient admission and could have been safely managed at a lower level of care.