Appeal type: Medical necessity
Decision: Upheld

Diagnosis: parainfluenza virus

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is upheld

The patient is a female child with a history of one day of coughing and an increased rate of breathing. Her father took her to the urgent care center, and they noted rales on examination of the chest and referred the child to the emergency room (ER) for evaluation.

In the ER she was noted to be pale and in respiratory distress with nasal flaring. The pulse oximeter reading was 100% on room air. On physical examination she was afebrile and was noted to have retractions with poor air entry and rhonchi audible at both lung bases. She was treated with 3 inhalation treatments of albuterol and atrovent. The white blood count was not elevated. She was also given IV (intravenous) magnesium sulfate was also given. A chest x-ray was normal. A venous blood gas was 7.3 pH (potential for hydrogen) and pCO2 (partial pressure of carbon dioxide) of 40. A respiratory viral panel was positive for parainfluenza virus. 

After parainfluenza virus was detected, she was treated with decadron and racemic epinephrine for a possible diagnosis of croup. She was also started on high flow nasal canula oxygen supplementation of 30% at 20 liters. The decision was made to admit her with a diagnosis of parainfluenza virus and respiratory failure with continued treatment with high flow nasal canula (HFNC) and albuterol every 2 hours PRN (as needed). 

The patient was treated in the ER for a cough and increased work of breathing. She tested positive for parainfluenza virus. She was started on oxygen supplementation despite the fact that her pulse oximeter was 100% on room air when she arrived in the ER. She was admitted to the PICU (pediatric intensive care unit) for ongoing treatment but the PICU admitting note indicated that she was breathing comfortably with no retractions or increased work of breathing. The order for albuterol was PRN and she did not require additional treatment during the hospitalization. 

The decision to admit was based on the initial presentation with increased work of breathing. There was improvement in her breathing during the time in the ER and there was no requirement for oxygen supplementation because the pulse oximeter reading had been in the normal range.

The decision to admit to the PICU was not consistent with the standard of care for a viral illness with the parainfluenza virus. This child could have been safely observed in the ER and the oxygen supplementation could have been weaned since the only abnormal physical examination finding reported by the PICU team was prolonged expiratory phase of breathing. 

The child could then have been safely discharged home with a follow up visit with the pediatrician in 24 - 48 hours.

The medical record does indicate that a blood culture obtained in the ER was found to be positive for Staph Lugdunesis after the child was discharged. The pediatrician could have followed up the child to determine the need for antibiotics for this positive blood culture.

The health plan acted reasonably with sound medical judgment in the best interest of the patient. The insurer's denial of coverage for the inpatient hospital services is upheld. Medical Necessity is not substantiated.