Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchiolitis.

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.  The denial is reversed. 

This patient is a female child who was sick for several days with coughing.  The patient was seen by her pediatrician days prior to the admission and was diagnosed with a strep throat.  The patient was started on Amoxil, albuterol and prednisone.  The patient had been receiving albuterol treatments at home but the patient was noted to have decrease in oral fluid intake.  On the day of admission, the patient was reported to have increased irritability, rapid breathing and difficulty catching her breath.  The patient was brought back to the pediatrician who again administered prednisone and three treatments with albuterol.  When the patient did not improve with this outpatient care, the patient's pediatrician arranged for an ambulance to bring the patient to the Emergency Room (ER) for additional treatment.  In the ambulance, the patient was treated with a nebulized combivent treatment.

In the ER, the patient was noted to have moderate respiratory distress with a significant increase in her work of breathing.  There were subcostal retractions, head bobbing and nasal flaring.  On examination, the patient was tachycardic and tachypneic, and the patient was described as having decreased air entry on examination of her lungs.  The patient's test for RSV infection was positive.  The patient's chest x-ray indicated a possible pneumonia on the right lung.  The patient was treated with intravenous (IV) saline fluid bolus and high flow oxygen supplementation.  The patient was also given methylprednisone, ranitidine and antibiotics.  The patient's venous blood gas was pH 7.35 with a pCO2 of 46 and a pO2 of 52, which indicated some retention of CO2.  With failure to respond to appropriate treatment in the ER, the decision was made to admit her to the PICU for ongoing care with albuterol every 2 hours for a diagnosis of Bronchiolitis.

Based on the review of the medical record provided and the literature, the patient was treated appropriately in the ER, and was appropriately decided for inpatient admission.  The patient presented with four day history of infection that progressively worsened despite multiple outpatient management at home and at the pediatrician's office.  The patient's increased work of breathing and decreased oral intake put the patient at high risk for dehydration and respiratory collapse.  The patient was noted to have poor air entry on exam, and the patient's blood gas values indicated that the patient was having some carbon dioxide retention.  These clinical signs and symptoms were concerning for acute respiratory failure.  The patient's persistent tachypnea, respiratory distress with work of breathing and inability to take adequate fluids by mouth despite ER treatment, indicated that a higher level of care and monitoring was medically necessary.  The patient required and received intravenous fluid hydration, antibiotics, albuterol every 2 hours and high flow oxygen supplementation during inpatient stay that were consistent with the standard of care.  Thus, based on the review of the literature, this patient met the clinical criteria for inpatient admission. 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is reversed.  The medical necessity is substantiated.