Appeal type: Medical necessity
Decision: Overturned

Breathing Problem
Inpatient Hospital

The patient is a male with atrial septal defect (ASD) unrepaired, and reactive airway disease (RAD) who presents with 1 day history of worsening shortness of breath (SOB) and fevers. Mother noticed at home that his oxygen saturation dropped to 82%. Mother gave a dose of budesonide and albuterol and placed him on 1 liter (L) oxygen (O2) via nasal cannula (NC) and he immediately responded with sat 100%. Mother states the medications did not help and he remained tachypneic, so she brought him in to the emergency room (ER). Mother also reports he was having poor by mouth (PO) intake and only had one wet diaper for the day so far.
On initial presentation the patient was febrile to 102.7 and tachypneic with decreased lung sounds throughout. He was given an hour continuous nebulization and a dose of steroids. He fell asleep and then was noted to be more tachypneic and retracting. He was also placed on supplemental oxygen via high flow nasal cannula (HFNC) to maintain oxygen saturation levels and for treatment of respiratory distress. Due to the need for respiratory support it was decided the patient needed to be admitted for further management. The case was discussed with the pediatric cardiology team, and they felt that the presentation not consistent with heart failure. The patient remained on HFNC through the night with supplemental oxygen at fraction of inspired oxygen (FiO2) 30% to maintain oxygen saturation levels greater than (>) 95%. The following morning, he was weaned off respiratory support and attending described him as looking great and eating well. He felt the patient's mother to be reliable and wanting to be discharged home. He recommended that the patient stay for another night but eventually cleared him for discharge home that day. The patient was sent home with Albuterol and Pulmicort nebulizer solution for his nebulizer.

The health plan's determination is overturned, in whole. 

The requested health service/treatment of inpatient say is medically necessary for this patient. This patient presented with tachypnea and respiratory distress. Although he was not significantly hypoxic, he was in distress enough to require respiratory support with high flow nasal cannula (HFNC). HFNC is used for those patients with marked respiratory distress with impending respiratory failure. It is used as an intervention to prevent the need for intubation. Patients on HFNC are often admitted to an Intensive Care Unit (ICU) setting although some institutions do admit to the general pediatric floor. These patients require close monitoring of their respiratory status as deterioration is a great risk in the event, they are not responding to the HFNC and need stepped up care. Also, patients with cardiac conditions and upper respiratory infections may experience more exaggerated respiratory distress as there may also be a component of cardiac compromise at work during times of stress. At times, their clinical course may be unpredictable, and they often need increased respiratory support and monitoring as they recover. Due to the intensity of intervention this patient required for respiratory support along with his underlying cardiac structural defect, inpatient stay was medically necessary for this patient.