Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath and wheezing
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a toddler male child with medical history significant for reactive airway disease treated with intermittent albuterol that presented to the emergency department (ED) with three-day history of cough and fever. He was seen in the ED and improved with CombiNebs and dexamethasone. The patient was taken back because of worsening tachypnea and shortness of breath with no benefit from albuterol. He was able to eat and drink at baseline. 

The patient's vital signs included temperature 38.0, heart rate 176, respiratory rate 52, and saturation 95% (percent). Examination was significant for tachypnea, no retractions, rales in the right middle and lower lung fields, and non-focal neurologic exam. Rapid influenza, respiratory syncytial virus (RSV), and COVID (Coronavirus disease) were negative. The patient's chest x-ray revealed opacity in the right lung field more than the left lung field. He was treated with three CombiNebs without resolution. He was also given Tylenol, Motrin, and a dose of Amoxil. The patient was admitted for monitoring. Admission orders included Amoxil, albuterol every four hours, consideration for additional steroid, antipyretics, and regular diet. The patient did well on the asthma pathway, continuing with albuterol every four hours and a five-day course of steroids. He remained hemodynamically stable, with intermittent fevers and good intake. He was deemed stable for discharge.

The proposed inpatient hospital admission was not medically necessary.

About half of all children experience an episode of wheezing in the first six years of life, often linked with a viral respiratory infection (e.g. ["for example"] RSV, rhinovirus, Human metapneumovirus, influenza). Children may even experience recurrent episodes of wheezing as triggered by viral infection. 

There are different classifications of wheezing in young children. Some children experience transient wheezing, others experience persistent wheezing. Persistent wheezing may be divided into two groups, immunoglobulin E (IgE) mediated or atopic and non-atopic. Treatment includes following asthma guidelines, although dosing may need to be tailored due to young age and small size. Inhaled steroids may be useful in reducing risk of viral-mediated wheezing. Leukotriene modifying agents may be helpful with a subgroup of children. Administration of macrolide antibiotics may reduce the risk of severe secondary lower respiratory tract infection in some children. Overall, there is a lot of interest in finding medications to reduce viral-mediated wheezing in children. 

This young male child with personal history of reactive airway disease and strong family history of asthma presented to the ED with viral respiratory infection with associated wheezing. There were infiltrates on chest x-ray representative of a viral-mediated process or reactive airway disease. The patient was treated per asthma guidelines and responded well to therapy. While this was his second presentation to the ED for the same symptoms, he responded well in the ED with the treatments that he received. He did not require acute inpatient hospital admission and could have been safely managed with prolonged monitoring in the ED or an observation stay.