Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lung infection 
Treatment: Inpatient admission 

The insurer denied the inpatient admission. The denial is overturned. 

Yes, the inpatient admission is medically necessary. 

The patient is a male child with medical history significant for reactive airway disease, speech delay, and small secundum ASD (atrial septal defect) versus PFO (patent foramen ovale),  that presented to the ED with four-day history of worsening productive cough and one-day history of trouble breathing. Vital signs included temperature 36.6, heart rate 151, respiratory rate 29, and 95% saturation in room air. 

Examination was significant for non-toxic appearance, erythematous pharynx bilateral, erythematous tympanic membranes with purulent material, tachycardia, mild tachypnea, crackles and minimal wheezing without retractions, and non-focal neurologic exam. Chest x-ray was obtained for possibility of pneumonia revealing right middle lobe infiltrate and left basilar infiltrate, consistent with pneumonia versus atelectasis and mild bronchiolitis/reactive airway disease. There was some concern for aspirated foreign body given age, developmental status, and right middle lobe infiltrate on x-ray. 

The patient was treated with one DuoNeb, a dose of amoxicillin, and Tylenol prior to admitting for further management. Following admission, additional orders included Pulmonary consult with recommendations for additional x-rays to rule out foreign body aspiration, albuterol every two to three hours, systemic corticosteroids, administration of ceftriaxone to cover possible pneumonia and bilateral otitis media, and ENT consultation. Decubitus x-rays showed resolution of infiltrates, suggestive of a viral process with asthma exacerbation. He was initially treated with albuterol as needed, but required more frequent routine albuterol. Steroids were added for treatment of asthma exacerbation. He was able to tolerate routine treatments. He was subsequently deemed stable for discharge. 

This young child, with history of speech delay and reactive airway disease, presented with several day history of fevers, cough, and increasing respiratory distress. His chest x-ray initially revealed infiltrate and was concerning for foreign body aspiration prompting treatment with antibiotics. Examination also revealed bilateral otitis media. Follow-up x-rays showed resolution of infiltrate, supportive of a diagnosis of viral respiratory infection and asthma exacerbation. The antibiotics were discontinued and he was placed on frequent routine albuterol as well as inhaled steroids. His symptoms resolved sufficiently that he was deemed stable for discharge, with a new diagnosis of intermittent asthma. 

When this child was initially admitted, he was treated for bilateral otitis media and community-acquired bacterial pneumonia. As his symptoms developed and evolved, it became clear that he did not have bacterial infections, rather had viral infection with asthma exacerbation. Although he had history of reactive airway disease in the past, he had not yet been diagnosed with asthma, prompting a significant change in management. Even though he was hemodynamically stable throughout his hospital stay with no need for supplemental oxygen and no impending respiratory failure, his case was sufficiently complicated to justify acute inpatient admission. Acute inpatient level of care was medically necessary and appropriate; he could not have been safely managed at a lower level of care.