Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Brochiolitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female child with a medical history of eczema, multiple food allergies, and multiple episodes of bronchiolitis who was taken to the emergency department (ED) with a five-day history of a cough and runny nose and one-day history of wheezing and shortness of breath despite bronchodilator treatments at home. The examination was significant for no acute distress, non-toxic appearance, increased work of breathing with tachypnea, moist mucous membranes, belly breathing with retractions, no nasal flaring, diffuse wheezing, and a non-focal neurologic exam, running around the ED playfully. 
A chest x-ray revealed a pattern suggestive of a viral infection or reactive airways disease with no focal consolidation. She was treated with nebulized albuterol, nebulized saline, Decadron, ibuprofen, and normal saline bolus. She improved somewhat, but continued to have belly breathing, tachypnea, and intercostal retractions. She was admitted to the pediatric floor for management of bronchiolitis. Admission orders included continuous cardiopulmonary monitoring, regular pediatric diet, albuterol every four hours, and pulmonology consult. The pulmonology consultation yielded a diagnosis of mild to moderate persistent asthma and recommendations to keep on albuterol every three to four hours, systemic steroids, nebulized budesonide twice daily, and albuterol inhaler with spacer every four to six hours. She improved over the course of the day and was deemed stable for discharge later in the afternoon to follow-up in two to three days. At issue is the medical necessity of an inpatient stay.

Acute inpatient admission was not medically necessary for this child.
Asthma is an inflammatory process characterized by airway obstruction due to airway hyper-responsiveness, bronchospasm, airway inflammation, and mucus production. Gas exchange abnormalities are due to ventilation/perfusion mismatch from atelectasis and airway over-distention. There are many possible triggers including exposure to allergens and upper respiratory viral infections. Asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough.
In the ED, primary management strategies include correction of hypoxia, rapid improvement of airflow obstruction, and prevention of progression. This is achieved with supplemental oxygen, bronchodilators, and steroids. Fluid hydration may also be necessary. For patients with moderate to severe exacerbations that do not respond to such intensive therapy in the ED, admission is necessary.
This young female child with an atopic dermatitis history and multiple episodes of bronchiolitis including Pediatric Intensive Care Unit (PICU) admission presented to the ED after failing bronchodilator treatment at home. She was treated aggressively in the ED but continued to demonstrate signs of distress. While it was not unreasonable for this child to remain in the hospital to monitor response to therapy, she was overall hemodynamically stable with no need for supplemental oxygen and no evidence of impending respiratory failure. She did not require acute inpatient admission and could have been safely managed at a lower level of care.