Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchiolitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay as not medically necessary.
The determination is overturned.

The patient was taken to the emergency department (ED) because of a two-day history of a cough, runny nose, and low-grade fever, and one-day history of moaning and crying, poor oral intake, and loose stools. He was noted in triage to be in respiratory distress with nasal flaring and retractions, was unable to lie flat, and had shortness of breath at rest. He appeared lethargic, with room air oxygen saturations from 91-94% (percent). Vital signs included a temperature of 99.9 degrees Fahrenheit, heart rate 159, and respiratory rate 32.
The examination was significant for ill appearance, moist mucous membranes, retractions, diffuse wheezing, a benign abdomen, and unremarkable neurologic exam. He was given a nebulized albuterol treatment and parenteral dose of steroids with subsequent improvement in room air saturation. Laboratory evaluation was significant for a normal white blood cell (WBC) count with left shift. He was treated with additional albuterol, as well as a normal saline bolus. He was reevaluated multiple times, demonstrating some improvement, but not sufficient for discharge home. He was admitted to the pediatric floor with a diagnosis of bronchiolitis and concerns for impending respiratory decompensation. A viral respiratory panel returned positive for enterovirus/rhinovirus. Coronovirus disease (COVID) testing was negative. Admission orders included pulse oximetry, albuterol every two hours, continued steroids, and close monitoring for respiratory distress. He did well overnight, taking some foods/fluids by mouth. He continued to have upper respiratory infection (URI) symptoms. His albuterol was weaned to every three hours. He continued to improve slowly and was able to wean to albuterol every four hours which he tolerated over the day. At that point he was deemed stable for discharge to home to complete five-day course of steroids and continue albuterol every four hours with close outpatient follow-up.
At issue is the medical necessity of an inpatient stay.

When this child was admitted, he was in sufficient respiratory distress that there was concern for progression to respiratory failure, he required albuterol treatments every two hours, and he was not eating or drinking sufficiently to sustain himself. He was at risk of decompensation, and a lower level of care would not have been appropriate.
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, generally affecting infants less than 12-24 months of age. 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 respiratory syncytial virus (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. A chest x-ray is usually only necessary in the presence of a 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 intravenous (IV) fluids is necessary.
This child presented with signs and symptoms of an upper respiratory infection combined with significant respiratory distress including retractions, nasal flaring, and inability to lie flat. He was not taking adequate nutrition or fluids by mouth and at one point was noted to be lethargic. The family history was significant for atopic disease. Prior to the expanded respiratory pathogen panel resulting, he was given a trial of albuterol with significant benefit so his care was transitioned to an asthma pathway including both bronchodilators and steroids. For the first 24 hours after admission, he required frequent treatments every two hours, and over the course of the next two days was able to consistently wean down eventually to every four hours. His appetite improved significantly as his work of breathing decreased. According to the documentation there was some initial concern of decompensation to respiratory failure, although he ultimately never had an oxygen requirement or needed assisted non-invasive ventilatory support. Because of the severity of his illness, and the resulting necessary care and intervention, acute inpatient status was medically necessary and appropriate. A lower level of care would not have been appropriate in this case.