Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory syncytial virus (RSV)

Treatment: inpatient services

The insurer denied coverage for inpatient services. The denial is reversed. 

This patient is a female born at over 30 week's gestation. The patient had a history of having been treated with albuterol in the past.  The patient had been sick for several days with a cough, difficulty breathing and a fever.  The patient had been on Motrin and Tylenol around the clock to control her fever.  The patient had not been eating well.  The patient's sibling had been sick with the respiratory syncytial virus (RSV) and was admitted to the Pediatric Intensive Care Unit (PICU). On the night prior to the admission, the patient was seen in the Urgent Care and was treated with albuterol.  When the patient's respiratory distress worsened, the patient was brought to the Emergency Room (ER) by the ambulance.

In the ER, the patient was noted to appear tired with significant increase in her work of breathing.  On examination, the patient exhibited subcostal retractions, and had crackles in both of her lungs. The patient's vitals showed tachycardia and tachypnea with a pulse oximetry ranging from 92-94%.  The patient spiked a fever in the ER to 102.5 degrees.  The patient was treated with intravenous (IV) fluids and high flow oxygen supplementation at 10 liters supplying 35% oxygen concentration.  The patient was treated with 2 combivent bronchodilator treatments with no improvement.  The patient's test for RSV was positive.  The patient's arterial blood gas was abnormal with a pH of 7.5, pCO2 of 25 and a pO2 of 145 which was consistent with a respiratory alkalosis.  The patient's chest x-ray was negative for pneumonia.  The patient's complete blood count (CBC) did not show an elevated white blood count but there was a shift to the left.  The patient was started on ceftriaxone. The patient's oxygen supplementation was increased to 12 liters at 40%, and the decision was made to admit the patient to the PICU for ongoing care for bronchiolitis.

Based on the review of the medical records provided, the patient was treated appropriately in the ER. The decision to admit the patient to the hospital was medically necessary and appropriate considering this patient's clinical presentation. This patient was lethargic and had tachypnea, hypoxia with respiratory alkalosis that required high flow oxygen supplementation. The patient's respiratory distress, increased work of breathing, fever, and low oral intake, put the patient at high risk for dehydration. The patient received 2 combivent bronchodilator treatments in the ER with no clinical improvement, and had failed treatment as outpatient with a visit to the Urgent Center. Based on the review of the literature, this patient met the clinical criteria for inpatient monitoring and treatment. The patient required ongoing treatment with intravenous fluids, antibiotics, and oxygen supplementation. Thus, inpatient admission was medically necessary to treat this patient's medical condition.

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

The carrier's denial of coverage for the inpatient services is reversed.  The medical necessity is substantiated.