Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Viral illness. 
Treatment: Inpatient Admission. 

The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a female who presented with fever, cough and wheezing. She was well until 2 days prior to presentation when she developed rhinorrhea. The next day she developed a dry cough and then she began to wheeze. Her temperature went up to 101 degrees Fahrenheit (F) and she was given acetaminophen. She was also eating and drinking less than usual. Later in the evening her cough worsened and she developed difficulty breathing. She was given albuterol at home but she did not improve and therefore she was brought to the emergency department for care. 
In the emergency department she had a temperature of 98.6 degrees F and her oxygen saturation was 94 percent (%). Her right tympanic membrane was erythematous and bulging. Her lung exam revealed tachypnea with shallow breaths with wheezing bilaterally, decreased air entry and subcostal retractions. Her laboratory values were obtained and she was given an Albuterol and Atrovent nebulized treatment as well as Prednisone. Her oxygen saturation dropped to 93 %. A chest x-ray showed findings consistent with bronchiolitis. She was also given a bolus of fluids and a dose of Ceftriaxone. She was admitted due to her low oxygen saturation and respiratory distress.
In the hospital she was initially given Albuterol every 2 hours and Solumedrol every 12 hours. She continued to have tachypnea and retractions, and her oxygen saturation dropped to levels of 91% and 92% so she required supplemental oxygen. Over time she improved, and her need for Albuterol decreased to every 3 and then 4 hours. By the time of discharge, she was tolerating room air, she was afebrile and drinking well. She was felt to be stable for discharge to home with follow-up as an outpatient. 

The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment and in the best interest of the patient. 

The patient presented with tachypnea, wheezing and respiratory distress. She was given appropriate and intensive treatments in the emergency department, but she continued to have respiratory distress. She also developed hypoxemia and required supplemental oxygen. She therefore required hospital admission for ongoing treatment with frequent bronchodilators (initially every 2 hours), intravenous fluids and supplemental oxygen as needed along with close monitoring with additional treatments as needed. 
The decision making at the time of admission for this patient was consistent with her young age, the presence of wheezing, respiratory distress and hypoxemia. The patient had the need for intensive treatments in an inpatient setting along with close monitoring for potential deterioration of her clinical status. 

According to the MCG Health Inpatient and Surgical Care Guidelines, 25th edition, Bronchiolitis; hospital admission is indicated for patients with hypoxemia and with tachypnea, wheezing, or retractions that persist despite observation care. 
This patient had hypoxemia with oxygen saturation levels as low as 91%, and also had persistent wheezing and retractions despite appropriate and intensive treatment in the emergency department setting. She therefore required admission for appropriate ongoing treatments, including supplemental oxygen, frequent bronchodilators, as well as monitoring.