Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory system-Breathing problems.
Treatment: Inpatient Hospital stay.

The health plan denied the inpatient hospital stay as not medically necessary.  The reviewer has overturned in whole the health plan's determination.

This is a pediatric patient with past medical history of Pediatric Intensive Care Unit (PICU) admission for acute respiratory failure secondary to enterovirus/rhinovirus requiring bi-level positive airway pressure (BiPAP) who presented to the emergency room (ER) with difficulty breathing that began a few hours prior to presentation. Patient had 2 days of congestion and upper respiratory infection (URI) symptoms as well as 2 episodes of vomiting at home. He was also having tactile fevers and was treated with Tylenol at home. Parents then noted significant belly breathing with retractions and nasal flaring which prompted a visit to the ER.  No known recent COVID exposure. In the ER vital signs temperature 100.3, heart rate 169, respiratory rate 32, oxygen saturation 96% on room air. Also with tachycardia, tachypnea, mild respiratory distress with bilateral (B/L) intercostal retractions, nasal flaring, belly breathing and diffuse crackles and rales B/L with mildly decreased air entry. Labs with white blood cell count (WBC) 24.7, COVID negative, respiratory viral panel positive for enterovirus and rhinovirus. A chest x-ray (CXR) was non focal. He was treated with albuterol but continued to be symptomatic. Due to persistent work of breathing and tachypnea, the patient was started on high flow nasal cannula (HFNC) and admitted to PICU. Physical exam on admission documents child to be tired appearing with HFNC in place. Comfortable on 22 Liters (L) HFNC without tachypnea or retractions. Air entry to bases with B/L rhonchorous breath sounds. He was admitted to the PICU with HFNC 22 L 30%, nothing by mouth (NPO) with intravenous fluids (IVF) at maintenance rate and gastrointestinal prophylaxis. 

The requested health service/treatment of inpatient stay is medically necessary for this patient.

He presented with respiratory distress and was ill appearing. Despite adequate ER management he continued with distress and had to be placed on high flow nasal cannula for additional respiratory support. HFNC is used for those patients with marked respiratory distress with impending respiratory failure. It is used as an intervention to prevent the need for intubation. These patients require close monitoring of their respiratory status as deterioration is a great risk in the event they are not responding to the HFNC and need stepped up care. Because of the intensity of intervention patient required for respiratory support inpatient stay was medically necessary for this patient. HFNC requires frequent respiratory assessments, which would need to be managed at inpatient level of care. He was placed NPO due to the respiratory support being provided and on a cardiopulmonary monitor. PICU progress notes documented during his stay, mild subcostal retractions while on HFNC. 

His condition would warrant a higher level of care. The literature recommends admission and close monitoring for patients with persistent respiratory distress after proper ER management has been implemented. In summary, based on his clinical findings of respiratory distress as evidenced by tachypnea, retractions, and increased work of breathing at the outset that required albuterol treatments followed by HFNC, he required inpatient level of care to safely manage his condition as clinical progression of his disease process and/or worsening is of very great concern and not appropriate to be managed at a lower level of care.