Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Tachycardia
Treatment: Inpatient Admission
The health plan denied the requested inpatient admission as not medically necessary. The health plan's determination is upheld.

The patient is a female child with unremarkable medical history and family history of asthma that presented to the emergency department (ED) with a four-day history of cough, subjective fever, and cough. Vital signs included a temperature of 37.0C., a heart rate of 147 beats per minute (bpm), and a respiratory rate of 25/minute with a 100% oxygen saturation in room air. The examination was significant for nasal congestion, erythematous posterior oropharynx without exudate, tachypnea, good bilateral air entry, tachycardia (heart rate 147-176 bpm), benign abdomen, no rashes, and non-focal neurologic exam. Group A Strep testing and rapid viral testing (COVID, respiratory syncytial virus (RSV), influenza were negative. The chest x-ray was negative. She was given a DuoNeb treatment and Decadron because of the family history of asthma. Pediatric Cardiology was consulted because of persistent tachycardia with recommendations to obtain labs and echocardiogram. Lab studies were significant for a white blood cell count (WBC) of 9.5, a carbon dioxide (CO2) of 17, a brain (or B-type) natriuretic peptide (BNP) of 542, a troponin I < 0.012, a thyroid stimulating hormone (TSH) of 0.377, and a free thyroxine (T4) of 1.50. She was admitted for further management of respiratory tract infection with tachycardia, rule out myocarditis versus hyperthyroidism.
Admission examination revealed a playful and active toddler, hemodynamically stable, clinically euthyroid, with no respiratory distress. The echocardiogram was normal, and the electrocardiogram revealed sinus tachycardia. Admission orders included continuous cardiopulmonary monitoring, regular pediatric diet, and maintenance intravenous (IV) fluids. She did well overnight with no fevers, tolerating her diet, with no oxygen requirement. The tachycardia resolved and she developed mild bilateral wheezing without retractions. She responded well to Albuterol. She was ultimately diagnosed with acute asthma exacerbation and was discharged to continue oral steroids for total five days as well as nebulized Albuterol every four to six hours for two days.
At issue is the medical necessity for the inpatient admission.

The health plan's determination of medical necessity is upheld, in whole.

No. An acute inpatient admission was not medically necessary.
About half of all children experience an episode of wheezing in the first six years of life, often linked with a viral respiratory infection (e.g., respiratory syncytial virus, rhinovirus. Human metapneumovirus, influenza). Children may even experience recurrent episodes of wheezing as triggered by viral infection.
This young female child with family history of asthma presented with several days of cough and subjective fever. She was not initially wheezing, but presented with persistent tachycardia, raising concerns for viral myocarditis or hyperthyroidism. Cardiac studies were unremarkable, chest x-ray was clear, and she developed wheezing over time responsive to bronchodilators. While it was medically necessary and appropriate to monitor for resolution of tachycardia versus deterioration, she remained hemodynamically stable with no fevers, no significant respiratory distress, no concerns for impending cardiorespiratory failure, and no metabolic derangements. She did not require acute inpatient admission and could have been safely managed at an alternate level of care.