Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchiolitis
Treatment: Inpatient Hospital Stay

The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient had a medical history significant for hemoglobin C trait who was well until approximately one week prior to admission when she developed cough, congestion, and runny nose. Her symptoms worsened, so she was taken to the emergency department (ED) five days prior to admission where she was treated with nebulized saline and discharged. She was seen by the pediatrician in follow-up the following day, where she was prescribed amoxicillin, prednisone, and albuterol. Her symptoms continued to worsen, and her oral intake and urine output decreased. Two days prior to admission, she was making only two wet diapers in two days. She was also vomiting after every feeding. She was again taken to the ED one day prior to admission where she was prescribed nasal saline drops and discharged home. She was taken to the ED for the third and final time because she was not eating and had not voided for over twelve hours. Vital signs included a temperature of 37.6 degrees Celsius, heart rate 138, and respiratory rate 38. Examination was significant for congestion, rhinorrhea, prolonged expiration, wheezing, and decreased air entry. Laboratory evaluation was significant for a normal white blood cell count (WBC), mild hyperkalemia, mild hypercalcemia, positive rapid respiratory syncytial virus (RSV), and pending blood culture. A chest x-ray revealed prominent perihilar lung markings. She was treated with three DuoNebs, methylprednisolone, and a normal saline bolus prior to admission for further management. Admission orders included intravenous (IV) fluids, albuterol every three hours with weaning as tolerated, nasal saline drops, and diet for age. She was able to tolerate albuterol every four hours. Cardiology was consulted because of a pansystolic murmur, with recommendations to follow-up in the outpatient clinic. She did well, with improved feeding and urine output. She was deemed stable for discharge home.
At issue is the medical necessity of an inpatient stay.

Acute inpatient admission was medically necessary for this patient. She had failed multiple attempts at outpatient management.
 
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. 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.

On examination, there may be 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.
Treatment is generally supportive, including hydration, supplemental oxygen, and assisted ventilation when necessary (continuous positive airway pressure (CPAP), 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. Hypertonic saline may be considered to facilitate mucociliary clearance. Antibacterial agents should only be used if there is a concomitant bacterial infection. Finally, hydration via enteral feedings and/or IV fluids is necessary.
This young female infant developed signs and symptoms consistent with worsening bronchiolitis, eventually testing positive for RSV. At the time of admission, she had been to the ED multiple times as well as to the pediatrician's office. She had failed conservative and symptomatic treatment, vomiting with each feeding, not drinking or voiding sufficiently, with increased work of breathing. She responded well to bronchodilator therapy and was able to discharge within a day. However, she had failed aggressive outpatient therapy multiple times, and was at risk for significant morbidity from her illness. The acute inpatient hospital stay was medically necessary and appropriate for the full duration.