Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Oxygen desaturations
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld. 

The patient is a female child with medical history significant for obstructive sleep apnea, bilateral sensorineural hearing loss with chronic and recurrent otitis media that presented in the outpatient setting for adenoidectomy and bilateral tympanostomy tube placement. She did well during the surgery but in recovery had oxygen desaturation to 88% without distress. She was treated with albuterol but had persistent desaturations so was placed on supplemental oxygen and admitted for further management. 

A pre-operative nasal swab returned positive for respiratory syncytial virus (RSV), consistent with pre-operative complaints of nasal congestion, nasal discharge, and sore throat. Physical examination was significant for mildly edematous uvula, high arching palate, clear anterior rhinoscopy, cotton in both ears, nasal cannula in place with saturations in the mid-90s, no increased work of breathing or wheezing, and non-focal neurologic exam. Admission orders included continuous pulse oximetry, nasal cannula oxygen with titration to maintain saturations greater than 92%, ofloxacin drops, Tylenol/Motrin as needed for pain, and regular diet. The pediatric intensive care unit (PICU) was notified and the patient was monitored closely for decompensation. She remained on supplemental oxygen overnight. 

Chest x-ray was obtained, concerning for viral pneumonia with bilateral interstitial opacities. Pain was well-controlled.  Pediatric consultation was obtained with recommendations for supportive care and minimum six-hours off oxygen including a period of sleep prior to discharge. She was weaned to room air and was stable for more than six hours so was deemed stable for discharge home.

No, acute inpatient admission was not medically necessary.
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 presence of respiratory syncytial virus (RSV), laboratory investigation is not typically necessary. In young infants, however, urinary tract infection may accompany respiratory syncytial virus (RSV) infection, so in a febrile infant, urine studies are warranted. Chest x-ray is usually only necessary in the presence of 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. 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.

In this case, the patient experienced oxygen desaturation post-operatively in the recovery room following adenoidectomy and tube placement necessitating treatment with supplemental oxygen. Pre-operative testing revealed respiratory syncytial virus (RSV) infection. The patient was monitored in the hospital overnight and the following day was able to successfully wean from supplemental oxygen and discharge home. While it was medically necessary and appropriate to monitor the child in the hospital, she was overall hemodynamically stable with no evidence of impending respiratory failure and no significant respiratory distress. She did not require acute inpatient admission and could have been safely and appropriately managed at a lower level of care such as observation.