Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Difficulty Breathing
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is overturned.

According to the documentation submitted, this is the case of a patient with a history of bronchiolitis. The patient presented to Mount Sinai South Nassau Emergency Department (ED) due to difficulty breathing. The note stated that the X-ray of the chest reported interstitial opacities bilaterally with left upper lobe consolidative abnormality. Findings for bilateral pneumonia superimposed in viral pneumonia. The patient was admitted for pneumonia. The patient was discharged to follow up with a pediatrician.

The insurer has denied coverage for full hospital admission. In their Final Adverse Determination letter, they write that they cannot approve the patient's request for admission and hospital care on appeal review. The request tells them that the patient went to the hospital for a lung infection (pneumonia). The plan clinical criteria consider a full hospital admission for a lung infection medically necessary when there are severe problems.

This is a child with a history of bronchiolitis who had a barking cough for 2 days. On the day prior to admission, the patient was seen in Urgent Care and was diagnosed with bilateral otitis media. The patient was treated with prednisone and a nebulizer during the visit to Urgent Care. The patient was then started on amoxicillin, prednisone, albuterol and budesonide.  The mother administered the budesonide and 2 doses of albuterol at home but because of concern for difficulty breathing the patient's mother brought the patient to the emergency room (ER) for further treatment.

In the ER (emergency room) the child was noted to have respiratory distress with retractions and an increased respiratory rate. On physical exam the patient was noted to have retractions, abdominal breathing, nasal congestion and rhinorrhea. A chest x-ray (CXR) showed upper lobe consolidation and bilateral interstitial opacities. A blood test was significant for an elevated white blood count (WBC) of 24,400, an elevated lactate of 6.6 and a low bicarbonate level of 15.3. The patient was treated with 3 nebulizer treatments with DuoNeb, prednisone, ceftriaxone and an intravenous (IV) bolus of normal saline. After treatment the patient was noted to have wheezing and a low oxygen saturation of 90-91% (percent). The patient was started on oxygen supplementation. A respiratory viral panel was positive for rhino/enterovirus and because of ongoing increased work of breathing and hypoxemia, the decision was made to admit the child with a diagnosis of pneumonia for ongoing treatment with albuterol, antibiotics and albuterol.

The insurer has denied coverage for acute in-patient admission to the hospital.

The patient was treated appropriately in the ER (emergency room) for a diagnosis of pneumonia following an Urgent Care visit and treatment in the ER for respiratory distress and increased work of breathing. The patient's WBC (white blood count) was elevated and there was concern for possible sepsis because of an elevated lactate level of 6.6 and a low bicarbonate level of 15.3. Following treatment in the ER (emergency room) the child was noted to have ongoing increased work of breathing, wheezing and hypoxemia that required oxygen supplementation. Based upon review of the medical record the admission to the hospital was medically necessary and the child could not have been safely discharged with ongoing need for oxygen supplementation.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for full hospital admission is substantiated.