Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient stay. 
The denial is upheld in whole. 

This patient is a male with a history of Erb-Duchenne palsy who was brought in after a few days of progressive cough. The patient's mother states that five days prior to admission he presented with intermittent cough and then 3 days prior to admission the cough had become constant with an associated temperature of 100F rectal. Two days prior to admission the cough persisted, and he developed a temp of 104F at which point his mother called the pediatrician. On the day prior to admission his cough progressed to a harsh constant barking cough. He was seen by his primary medical doctor (PMD) and tested for rhinovirus/enterovirus and respiratory syncytial virus (RSV). Results were positive for both. The patient was prescribed prednisolone for 3 days.
He returned to the PMD earlier on the day of presentation and was found to be tachypneic, with increased work of breathing, by mouth (PO) intolerant with decreased number of wet diapers as he usually has 6 plus (+) wet diapers and now only had 3. Normally the patient has 3-4 bowel movement (BM)s a day, now had 1. His mother endorses congestion, runny nose, sneezing, and drooling. She denied ear pain, rash, skin color changes or seizures. On exam, his vital signs were recorded at a heart rate (HR) of 136, respiratory rate (RR) was 38, temperature (Temp) was 98.7, oxygen (O2) saturation was 100% on room air.
He was described as crying on exam, irritable and in moderate distress, with dry mucous membranes. His lungs with rhonchi and wheezing. The patient was admitted with a differential diagnosis of respiratory syncytial virus (RSV) bronchiolitis versus (vs) bacterial pneumonia. Orders at admission for vitals every (q) 4 hours (hrs), strict intake and output (I's and O's), intravenous fluids (IVF) and supportive treatment of nasal suctioning, as needed (PRN) supplemental O2 and monitoring for signs and symptoms of respiratory failure. Throughout the hospital course, dehydration was managed as per unit protocol and progressed to tolerating PO intake well and the patient remained afebrile. As per attending, the child was cleared medically for discharge home.
At issue is the medical necessity of the Inpatient stay.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Inpatient Stay was not medically necessary for this patient.
This patient presented with respiratory symptoms and fever and worsening cough. He was found to be RSV positive, and a chest x-ray (CXR) was negative. He was also notably having decreased PO intake. At the time of presentation, he was described as having some retractions and dry mucous membranes. He was treated with a normal saline (NS) bolus but there is no documentation of a follow up on his hydration status after the bolus. His urine specific gravity (SG) was 1020 which was not indicative of clinically significant dehydration. His laboratory studies did not support significant dehydration. There is no documentation of sustained tachypnea/respiratory distress nor is there documented hypoxia.
The patient did not require any highly skilled or technical care during his hospitalization. There is no mentioned sustained accessory muscle use or respiratory distress. He was tolerating PO well by the morning after admission at which time he lost his intravenous (IV) line and there were no signs of dehydration necessitating replacement of his IV line. His labs were unremarkable with no elevated inflammatory markers noted on admission or any significant aberrations in his electrolytes. He was medically cleared for discharge the day after admission. 
Therefore, the Inpatient stay was not medically necessary.