Appeal type: Medical necessity
Decision: Upheld

Diagnosis: RSV (respiratory syncytial virus) infection
Treatment: Inpatient emergency admission
The insurer denied the inpatient emergency admission.
The denial is upheld.

The patient is a toddler male child. He presented to the ED (emergency department) with known RSV (respiratory syncytial virus) infection, increased work of breathing, and wheezing. The mother reported two-week history of cough, worsening over the last two days with wheezing and increased work of breathing, no fevers, decreased activity, tolerating fluids. He had been seen earlier in the day, where he received an albuterol treatment with some improvement and prescribed albuterol every four hours.

The patient's vital signs included temperature 37.4, heart rate 137, respiratory rate 34, oxygen saturations 96% in room air. Examination was significant for tachypnea, accessory muscle use, wheezing in all lung fields, moist mucous membranes, regular heart rate and rhythm, benign abdomen, and non-focal neurologic exam. He was treated with three DuoNebs and steroids. Upon re-evaluation, his oxygen saturations had dipped to 88-92%, necessitating treatment with supplemental oxygen.

The patient was admitted for further management. Admission orders included albuterol every two hours, steroids for five days, respiratory scoring pathway, regular pediatric diet, asthma education, and continuous pulse oximetry while on supplemental oxygen. Treatments were weaned incrementally to every four hours. He continued to improve and was deemed stable for discharge 2 days later to continue albuterol and complete five days of steroids.

The inpatient admission was not medically necessary.

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.

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. However, if the child is considered to be at risk for atopic disease or exacerbation either by personal or family history, a trial of bronchodilator treatment is a reasonable course of action. For those that respond, an asthma pathway may provide significant benefit including steroids in addition to the bronchodilators.

This young male child with strong family history of asthma presented to the ED (emergency department) twice with wheezing and increased work of breathing, testing positive for RSV (respiratory syncytial virus) during the first visit. When he returned the second time, his saturations dipped below 90% prompting brief treatment with supplemental oxygen. He responded to steroids, so was treated initially with albuterol every two hours. While it was reasonable and appropriate to monitor him in the hospital for improvement versus decline, he was overall hemodynamically stable with no evidence of impending respiratory failure. He did not require acute inpatient admission, and could have been safely managed at lower level of care.