Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cough, wheezing, fever.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is overturned.

The patient is a toddler aged female twin born prematurely at 35-6/7-weeks' gestation due to placental abruption and hospitalized for five days due to "congenital anemia" requiring transfusion, with medical history significant for patent foramen ovale, multiple admissions for respiratory distress including pediatric intensive care unit (PICU) (no intubations or high flow nasal cannula [HFNC]), and strong family history of asthma including deaths due to respiratory failure. The patient presented to the emergency department with one-day history of cough, wheezing, decreased activity, and tactile fever. Her twin brother was hospitalized initially in the pediatric intensive care unit (PICU) at the time with respiratory syncytial virus (RSV) bronchiolitis. The mother attempted treatment with nebulized albuterol (with no effect) before calling emergency medical services (EMS). The patient was treated with one DuoNeb enroute. 
In the emergency department, the patient's vital signs included temperature 37.1, heart rate 142, respiratory rate 38, with 96% saturation in room air. The patient was treated with three DuoNebs, albuterol, parenteral steroids, and an intravenous fluid bolus with no benefit. She was placed on high flow nasal cannula (HFNC) up to 15 liters per minute (Lpm). Laboratory evaluation was significant for respiratory acidosis (venous potential of hydrogen [pH] 7.30, partial pressure of carbon dioxide [pCO2] 49.8, bicarbonate 24.5), anemia with hemoglobin 10.3, leukocytosis with white blood cell (WBC) 15.3 thousand (K), thrombocytosis with platelets 501 thousand (K), and rapid respiratory syncytial virus (RSV) positive. Chest x-ray was negative. The patient was subsequently admitted to the pediatric intensive care unit for acute respiratory failure secondary to respiratory syncytial virus (RSV) bronchiolitis. The patient was gradually weaned down to high flow nasal cannula 15 liters per minute overnight. After six hours of continuous albuterol, the patient tolerated wean to treatments every hour. She continued to demonstrate signs of distress with belly breathing and subcostal retractions. She had no fevers but remained tachycardic at times. She was able to wean to maintenance intravenous fluids. The patient was subsequently able to wean from high flow nasal cannula and to albuterol every two hours, with plans to transfer to the pediatric floor and continue weaning as tolerated. The patient's diet was advance to regular diet for age and intravenous fluids were further weaned to half-maintenance. Once settled on the pediatric ward, the albuterol and steroids were discontinued, and the patient was maintained on nebulized normal saline every three hours, with regular diet off intravenous fluids, continuous cardiopulmonary monitoring, and plans for social services consultation. She was deemed stable for discharge to follow-up with her pediatrician in two to three days.

The acute inpatient admission was medically necessary for this patient.

This young female child born prematurely with strong family history of asthma presented to the emergency department in impending respiratory failure. She required non-invasive ventilatory support with high flow nasal cannula up to maximum dosing (20 liters per minute) as well as prolonged continuous albuterol before clinically improving. Except for intubation, the last resort for patients with severely reactive airways, the patient received the maximum care available to treat her acute respiratory failure due to respiratory syncytial virus bronchiolitis. The care that the patient received was most consistent with acute inpatient (critical) level of care. A lower level of care was not appropriate or safe in this case. The patient was at the extreme of her illness, requiring the highest level of skilled care to recover safely.