Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bronchiolitis
Treatment: Inpatient hospital admission

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

This is an infant with a viral illness for 7 days. The sibling had been sick with respiratory syncytial virus (RSV). The child had been hospitalized on two previous occasions during this current illness. The child had wheezing, coughing and nasal congestion. A chest x-ray had been obtained during the prior hospitalizations and it was reported as being normal. The child had been administered normal saline via a nebulizer three times a day at home since the second admission to the hospital, but the mother returned to the emergency room (ER) when the child continued to have increased work of breathing. There was a family history of asthma in both the mother and father.

In the ER, he was noted to have mild respiratory distress with nasal flaring, intercostal retractions and wheezing. His pulse oximeter was reported as normal. The record indicated that the child had been feeding well and urinating normally. He had tachypnea and increased work of breathing. He was treated with one nebulization treatment with albuterol and an oral dose of dexamethasone. When there was no improvement in his mild respiratory distress, the decision was made to admit him to the hospital with a diagnosis of bronchiolitis and a plan to continue normal saline via the nebulizer. There was no record of the child requiring oxygen. The physician requesting the appeal indicated that the oxygen saturation in the ER was in the low 90's but this reviewer did not see documentation of this in the medical record. 

The child could have received a minimum of three treatments over one hour with albuterol which is the appropriate management for status asthmaticus. The child could also have received intravenous steroids to assess whether there would be a clinical response. The family history of asthma and the failure to respond to nebulized normal saline at home placed this child at an increased risk for acute asthma. Treatment with several nebulized administrations of bronchodilator could have prevented the need for the third hospitalization during this illness. The decision to admit for continued nebulized normal saline was not consistent with the standard of care for RSV illness which routinely does not last for 7 days. Had there been improvement with albuterol the child could have continued with steroids and albuterol at home. 

According to Piedra and Stark "SEVERITY ASSESSMENT - Severe bronchiolitis is indicated by persistently increased respiratory effort (tachypnea; nasal flaring; intercostal, subcostal, or suprasternal retractions; accessory muscle use; grunting), hypoxemia, apnea, or acute respiratory failure [1,2]. 
Risk factors for severe disease and/or complications of bronchiolitis include [3-8]:
1) Prematurity (gestational age <37 weeks)
2) Age <12 weeks
3) Chronic pulmonary disease, particularly bronchopulmonary dysplasia (also known as chronic lung disease)
4) Congenital and anatomic defects of the airways
5) Congenital heart disease
6) Immunodeficiency
7) Neurologic disease

The inpatient hospital admission is not considered medically necessary for this patient.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial is upheld. Medical Necessity is not substantiated.