Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever, cough, nasal congestion, decreased intake 
Treatment: Inpatient admission 

The insurer denied the inpatient admission. The denial is overturned. 

Yes, the proposed inpatient admission is "medically necessary". 

The patient is a female child. He presented to the ED with six-day history of fever to 101, dry cough, nasal congestion, and decreased intake. 

The patient's vital signs included temperature 37.1, heart rate 148, respiratory rate 24 and 95% oxygen saturation in room air. Examination was significant for non-toxic appearance, nasal congestion with rhinorrhea, moist mucous membranes erythematous pharynx, bilateral rales with mild subcostal retractions, prolonged expiratory phase, and non-focal neurologic exam. Rapid RSV (respiratory syncytial virus) testing was positive. Laboratory evaluation revealed leukocytosis (WBC [white blood count] 11.6K) with left shift (75% neutrophils, 6% bands), and elevated CRP (C-reactive protein) (7.7). Blood cultures were pending. Chest x-ray revealed prominent peribronchial lung markings without consolidation or pleural effusion. 

The patient was treated with nebulized saline and a normal saline bolus. She was not taking anything by mouth in the ED, and she had on and off signs of respiratory distress (nasal flaring, tachypnea, retractions), so she was admitted for further management. Admission orders included nebulized saline as needed, albuterol every two hours, parenteral steroids, anti-pyretics, and regular diet for age. 

The patient spiked a fever overnight to 101.7 responsive to Tylenol. Her breathing and cough symptoms had improved per the mother. She was eating well. Blood cultures remained negative. Her albuterol was spaced to every four hours. She continued on the parenteral steroids and nebulized saline as needed. She had intermittent desaturations the next night as low as 88% while sleeping (low 90s while awake). Albuterol was increased to every three hours. She was placed on continuous pulse oximetry. She was changed to enteral steroids. 

The patient' lowest oxygen saturation was 91%. She was not eating or drinking as much, so an IV was placed for fluids. She continued to have wheezing but was comfortable. She continued to receive enteral steroids and albuterol every three hours. Aerosol mask was provided to maintain saturation greater than 95%. 

The patient was having no further desaturation spells, her appetite had improved, and she had no signs of respiratory distress. She was deemed stable for discharge home, to continue albuterol every four hours for five days and to follow-up with her pediatrician. 

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 are 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 RSV, laboratory investigation is not typically necessary. In young infants, however, urinary tract infection may accompany 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 (CPAP [continuous positive airway pressure], 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. There is no place for corticosteroid administration because the evidence has shown no benefit when used alone and only tentative benefit when used in conjunction with bronchodilators. Use of supplemental oxygen is at the clinician's discretion, particularly if oxygen saturation as measured by pulse oximetry is greater than 90%. There is no evidence to suggest that application of supplemental oxygen for saturation above 90% adds any benefit and may in fact prolong hospital stay. For this reason, continuous pulse oximetry is not considered standard. Antibacterial agents should only be used if there is a concomitant bacterial infection. Finally, hydration via enteral feedings and/or IV fluids is necessary. 
 
This young child presented to the ED with signs and symptoms consistent with bronchiolitis. Chest x-ray was not consistent with pneumonia, but diagnostic testing was positive for RSV, confirming a diagnosis of RSV bronchiolitis. While continuous pulse oximetry is not standard per the guidelines, spot testing overnight revealed episodes of desaturation as low as 88%, prompting administration of supplemental oxygen via aerosol mask. Bronchodilator therapy is also not consistent with treatment guidelines unless there is history of asthma/reactive airway disease or strong family history of asthma. This child was treated with bronchodilators in the absence of personal or family history of atopic disease, but documentation suggested that it provided her with some relief. Finally, particularly toward the end of her hospital stay, she was not drinking sufficiently to sustain herself, necessitating return to IV fluid therapy. Taking all of these into consideration, this child could not have been safely managed at a level of care lower than acute inpatient level of care. The entirety of the hospital stay was medically necessary and appropriate.