Appeal type: Medical necessity
Decision: Overturned

The patient is a male that presented for bronchoscopy. He was diagnosed with bacterial bronchitis and moderate-persistent asthma two years prior. He was experiencing persistent wet cough and recurrent fevers resistant to outpatient treatment, so underwent bronchoscopy, revealing enlarged tonsils/adenoids and mucopurulent bronchitis with reactive mucosa. He was subsequently treated with Dulera and Asmanex for persistent cough. He also had recurrent otitis media requiring ear tubes, prompting evaluation for cystic fibrosis and primary ciliary dyskinesia (both negative). He was finally asymptomatic briefly, followed closely by Pediatric Pulmonology, but experienced recurrence of symptoms prompting return to Asmanex treatment. He continued to experience symptoms, so was referred again for bronchoscopy with bronchoalveolar lavage to determine infectious etiology and obtain a sample for primary ciliary dyskinesia screening. The procedure was performed as a planned outpatient procedure. Bronchoscopy revealed severe mucopurulent bronchitis and deep mucous impaction, sufficiently concerning to prompt admission to the pediatric ward for parenteral and enteral antibiotic therapy and further evaluation for pulmonary disease.

Admission orders included ceftriaxone twice daily, Bactrim, Solumedrol, chest physiotherapy (Vest treatment) with albuterol treatments three times daily, manual chest physiotherapy daily, mometasone twice daily, and regular diet. Plans were made to obtain computed tomography (CT) scan of both sinuses and chest. He continued to have cough with mucous production early in his hospital stay, with improvement over the course of several days. Dose adjustments were made in both antibiotics and anti-inflammatory medications. Titers were obtained for both diphtheria and Pneumococcus to assess immune function (he had been vaccinated against both). Cultures were positive for Streptococcus pneumoniae and Moraxella catarrhalis, so plans were made to vaccinate with Pneumovax 23 (and influenza) prior to discharge. Sinus CT revealed multiple areas of partial opacification and mucosal thickening. Chest CT revealed mild central and lobar bronchiectasis most notably involving the upper and lower segmental bronchi on the right and the lingular subsegmental bronchi. He was discharged to complete a 21-day course of Bactrim and cefdinir.

The health plan's determination is overturned.

This patient was ill with cough and fevers for over two years, refractory to appropriate outpatient management including outpatient bronchoscopy. He presented for a second bronchoscopy in an effort to further define and diagnose his condition and was found to have even worse infection with mucous impaction. He was subsequently admitted for parenteral antibiotic treatment, enteral antibiotic treatment, aggressive airway clearance, and further diagnostic studies. He was found to have poor response to vaccination as well as evidence of bronchiectasis and chronic sinusitis on CT scan. In order to prevent ongoing morbidity and progression of his disease, it was medically necessary and appropriate to admit for parenteral antibiotics and diagnostic studies. The full duration of his hospital stay was medically necessary, consistent with standard of care, care guidelines, and the current literature.