Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Worsening Nasal Congestion, Cough and Rapid
Breathing (Human Metapneumovirus)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male child that was referred to the emergency department (ED) by the pediatrician for evaluation of respiratory distress. He presented with five-day history of nasal congestion, clear rhinorrhea, and cough. He was taken to the emergency department (ED) with low-grade fever where he tested positive for human metapneumovirus (HMV). He was discharged home in stable condition. 

Overnight he had two episodes of vomiting and associated decreased appetite. On this day, he presented to the pediatrician for follow-up and was noted to have subcostal and intercostal retractions and tachypnea. He was treated with albuterol and sent to the emergency department (ED) for further management. Vital signs included temperature 99.1, heart rate 142, and respiratory rate 28 with 96% saturation in room air. Examination was significant for moderate distress with but no recorded retractions or wheezing. Laboratory evaluation was significant for mild leukocytosis (white blood cell [WBC] count 16.9 thousand [K]) and elevated C-reactive protein (CRP) (1.13). The patient's chest x-ray was unremarkable. He was admitted for ongoing management of respiratory distress and reactive airway disease secondary to human metapneumovirus (HMV). 

Admission orders included albuterol every three hours advancing to every four hours as tolerated, pulse oximetry checks every four hours, prednisolone, Pedialyte with oral feeds as tolerated, antipyretics, and nasal saline with suctioning. He remained afebrile overnight with improved cough and shortness of breath. He was drinking closer to baseline with good urine output. Albuterol was advanced to every four hours. He continued to improve and was deemed stable for discharge.

No, acute inpatient admission was not medically necessary. This child could have been safely managed at a lower level of care.
Bronchiolitis is an inflammatory process that affects predominantly small airways. Acute bronchiolitis is a clinical diagnosis given to the following constellation of signs and symptoms: viral upper respiratory prodrome followed by increased respiratory effort, wheezing, diffuse bilateral crackles, generally affecting infants less than 12 to 24 months of age. The most common causative agent is respiratory syncytial virus, but other viruses can cause bronchiolitis as well, including adenovirus, rhinovirus, influenza, enterovirus, parainfluenza, and human metapneumovirus. Non-viral causes include mycoplasma, chlamydia, fungi, and mycobacteria. Bronchiolitis typically starts in the upper airways and spreads to the lower airways within a few days, resulting in inflammation, edema, mucous production, and bronchospasm. Infants with bronchiolitis usually present with tachypnea, tachycardia, and prolonged expiratory phase. High fever is uncommon. 

On examination, there may be signs of respiratory distress, including wheezing, nasal flaring, retractions, and tachypnea. If there is significant congestion, infants may exhibit signs of dehydration from inability to feed. Other than confirmatory testing for presence of respiratory syncytial virus (RSV), laboratory investigation is not typically indicated. In young infants, however, urinary tract infection may accompany respiratory syncytial virus (RSV) infection, so in a febrile infant, urine studies are warranted. Chest x-ray is usually only necessary in the presence of significant fever, hypoxia, or underlying cardiopulmonary disease. A conservative approach to management is generally appropriate, particularly for the very young in whom apnea must be a consideration. Indications for hospitalization vary from institution to institution and practitioner to practitioner, with quite a bit of debate, but typically include the following: moderate to severe respiratory distress, including nasal flaring, tachypnea, retractions; hypoxia, with saturations less than 90 to 92%; poor feeding or dehydration; cyanosis; history of apnea; infants that are considered high risk either by very young age or underlying medical condition; poor social situation; severe malnutrition; and uncertainty over the diagnosis. 

Treatment is generally supportive, including hydration, supplemental oxygen, and assisted ventilation when necessary (continuous positive airway pressure [CPAP], high flow nasal cannula oxygen, mechanical ventilation). The current recommendation is not to use bronchodilator medications including epinephrine and albuterol because studies have failed to show sustained benefit. However, if the child is considered to be at risk for atopic disease or exacerbation either by personal or family history, a trial of bronchodilator treatment is a reasonable course of action. For those that respond, an asthma pathway may provide significant benefit including steroids in addition to the bronchodilators. Hypertonic saline may be considered to facilitate mucociliary clearance. Antibacterial agents should only be used if there is a concomitant bacterial infection. Finally, hydration via enteral feedings and/or intravenous fluids is indicated.

This child presented to the emergency department (ED) with known human metapneumovirus (HMV) infection and signs and symptoms consistent with either bronchiolitis or reactive airway disease (no known history of reactive airway disease or asthma, no family history). While the patient had evidence of respiratory distress, responding well to bronchodilators, he was overall hemodynamically stable with no supplemental oxygen requirement, no concern for impending respiratory failure, and no severe distress. He did not require acute inpatient admission and could have been safely managed at a lower level of care such as observation.

Yes, the health plan acted reasonably.