Appeal type: Medical necessity
Decision: Upheld

Diagnosis: RSV bronchiolitis.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male infant that was taken to the ED for increased coughing  when he was diagnosed with RSV (respiratory syncytial virus). He was afebrile, with rhinorrhea, productive cough, shortness of breath, poor feeding, and decreased wet diapers. Concurrently, both parents had respiratory infections and a sibling had been diagnosed with influenza. 

The patient's vital signs included heart rate 155 and respiratory rate 35. Examination was significant for consolable crying, good tone, strong cry, clear nasal drainage, retractions and wheezing, tachycardia, benign abdomen, and non-focal neurologic exam. Laboratory evaluation was significant for metabolic acidosis (CO2 [carbon dioxide] 19), normal WBC (white blood cell) count (10.56K), anemia (hemoglobin 11.1), normal urinalysis, positive PCR (polymerase chain reaction) for RSV, and negative testing for influenza. Chest x-ray findings were consistent with bronchiolitis. 

The patient was admitted to the pediatric service for ongoing treatment of RSV bronchiolitis and dehydration. Admission orders included high flow nasal cannula (HFNC) at 4L, albuterol treatments every 6 hours, and maintenance IV fluids. He responded well to bronchodilators and was able to wean from HFNC to room air. He had one temperature spike but was otherwise afebrile. He was able to feed well, maintaining good urine output. He was deemed stable for discharge to follow-up with his pediatrician in one to two days.   

No, the Inpatient admission was not medically necessary.

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.
 
This young male infant with known RSV infection presented to the ED with signs and symptoms of mild dehydration and respiratory distress. He responded well to a brief period of ventilatory support with HFNC as well as bronchodilators and IV hydration. While it was reasonable and appropriate to monitor this young infant in the hospital for potential apnea, worsening dehydration, and worsening respiratory distress, he was overall hemodynamically stable, responsive to treatments, with no signs of impending respiratory failure or sepsis. He did not require acute inpatient admission and could have been safely managed at a lower level of care such as observation.