Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchiolitis / respiratory distress.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male child. He presented to the ED with a three-day history of cough and rhinorrhea, and one-day history of increased work of breathing, fussiness, and one episode of vomiting. He had no fevers, and he was eating at baseline. 

The patient's vital signs included temperature 36.5, heart rate 191, respiratory rate 66, and 95% oxygen saturation in room air. His examination was significant for consolable fussiness, moderate respiratory distress with intercostal and subcostal retractions, diffuse crackles with few wheezes, benign abdomen, normal perfusion, and non-focal neurologic exam. Respiratory viral panel was obtained. He spiked fever to 38.3 and so was treated with Tylenol. Chest x-ray was obtained and revealed hyperinflation with mild perihilar streaky opacities and minimal peribronchial cuffing suggestive of bronchiolitis. 

Because of ongoing increased work of breathing unresponsive to albuterol, he was placed on high flow nasal cannula (HFNC), and he was admitted to the PICU (pediatric intensive care unit) for continued management. Admission orders included continued HFNC at 2L, with chest physiotherapy and suctioning every two hours and as needed, nothing by mouth, IV fluids, and famotidine for GI (gastrointestinal) prophylaxis. Viral panel returned positive for rhinovirus/enterovirus. He remained on HFNC with FiO2 0.30 for respiratory insufficiency in the setting of viral bronchiolitis. He failed to respond to a bronchodilator trial. 

HFNC was slowly weaned to room air. The patient remained afebrile and in room air overnight, and he was able to tolerate a regular diet for age. He was deemed stable for discharge to follow-up with his pediatrician.

Yes, the Inpatient admission was medically necessary.

On examination, there are 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 RSV (respiratory syncytial virus), 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. Chest x-ray is usually only necessary in the presence of 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.

This young child with unremarkable medical history presented at the peak of symptoms including respiratory distress and cough, diagnosed with viral bronchiolitis secondary to rhinovirus/enterovirus infection. He initially required high flow nasal cannula support with supplemental oxygen to treat respiratory insufficiency. He was able to slowly wean from ventilatory support as well as supplemental oxygen, concomitant with tolerating a regular diet. Although he was only in the hospital for two days, the care that he received was most consistent with acute inpatient management. He could not have been safely managed at a lower level of care.