Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bronchiolitis. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

This is a child who had fever and had been coughing for two days. There were several members of the family who were also sick with viral symptoms and coughing. The birth history and past medical history was unremarkable. The mother noted that the child had increased rate of breathing and was concerned and brought the child to the emergency room (ER) for evaluation.

In the ER the child was noted to have a fever of 102.3 degrees and was noted to have an elevated respiratory rate of 54 with abdominal retractions. The pulse oximeter reading was 98% on room air. On physical examination the breathing was described as not labored with no nasal flaring. On examination of the lung, coarse breath sounds were noted with no audible wheezing. Subcostal retractions were noted. The mother indicated that the child had been feeding and had normal urination at home. The child was treated with a nebulizer treatment with normal saline and was started on respiratory treatment with a high flow nasal cannula (HFNC) at a rate of 6 liters with room air. A urine specific gravity was elevated at 1.030. The child was given intravenous (IV) fluids at a maintenance rate and oral feedings were discontinued. Based on the persistent increased respiratory rate and subcostal retractions the decision was made to admit the child to the hospital for ongoing treatment with IV fluids and HFNC with a diagnosis of bronchiolitis. 

The insurer has denied the medical admission as being not medically necessary. 

The patient was treated appropriately in the ER for coughing, and increased work of breathing. The increased work of breathing did not improve with treatment with HFNC and room air and IV fluids. Although the child had an elevated urine specific gravity of 1.030 a bolus of IV normal saline was not considered necessary by the clinician in the ER. The child was treated only with a saline nebulizer treatment and a bronchodilator albuterol was not administered because the clinician did not consider this treatment medically necessary. A chest x-ray and a blood gas were not obtained because the clinician caring for the child did not consider these tests were necessary. The admitting note by the admitting physician indicated that the child had a normal oxygen level of 98% and unlabored breathing on physical examination. 

The decision to admit the child with a diagnosis of bronchiolitis was not consistent with the standard of care for treatment of bronchiolitis in a child with no evidence of hypoxemia. The child did not have a toxic appearance, poor feeding, lethargy, nasal flaring, or cyanosis. The respiratory rate was not above 70 breaths per minute.

This child could have been treated in the ER with a bolus of IV normal saline to address the high urine specific gravity and possible dehydration. The child could have benefited from a nebulizer treatment with albuterol to assess for improvement in the rate of breathing. The child could have been continued with treatment in the ER with IV fluids and saline nasal treatments for a few hours and allowed to eat to assess for stabilization of the respiratory status. Although the child was a young infant, the clinical status reported by the admitting physician indicated that the child did not have labored respiration and the pulse oximeter reading was 98% on room air. With a longer period of observation and appropriate treatment in the ER there was a good chance that the child could have been safely discharged with a follow up appointment with the pediatrician in 24-48 hours. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is not substantiated.