Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System.
Treatment: Inpatient Hospital.
The insurer denied: Inpatient stay.
The denial is: Upheld in whole.

The patient is a male with medical history significant for mild intermittent asthma that presented to the emergency department (ED) with one-day history of barking cough, fever to 102, and noisy breathing. Vital signs included temperature 39.3, heart rate 171, and respiratory rate 32, with an oxygen saturation of 97% on room air. Examination was significant for moist oral mucosa, stridor at rest, harsh breath sounds. He was treated with dexamethasone and racemic epinephrine. He was observed in the ED for 90 minutes, with return of stridor while sleeping. He was given a second dose of racemic epinephrine, after which he was admitted to the Pediatric Intensive Care Unit (PICU) for further management of croup. Testing revealed influenza B infection. He received his first dose of Tamiflu in the ED. Admission orders included regular diet for age, continued Tamiflu, and Tylenol as needed for fever. He did well overnight, with no distress and no stridor. He was deemed stable for discharge, to continue course of Tamiflu. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld, in whole.

Croup, or laryngotracheobronchitis, is a viral infection of the glottis and subglottic regions and is the most common form of acute upper respiratory obstruction. Typically, patients start with upper respiratory tract infection symptoms, with runny nose, sore throat, cough, and low-grade fever. The "barking" cough then develops, including hoarseness and inspiratory stridor. Low grade fever may persist and may spike to 104. Symptoms are classically worse at night and persist for the better part of a week. Agitation worsens the symptoms. Croup is a clinical diagnosis, although neck radiographs may reveal typical subglottic narrowing ("steeple sign"). Although the differential diagnosis includes epiglottitis, these patients are typically ill in appearance, with drooling and tripod positioning. Sudden onset stridor may represent foreign body aspiration, but there is no evidence of infection. The mainstay of treatment of croup is airway management, with most children managed safely at home. For moderate to severe croup, racemic epinephrine may help to reduce laryngeal mucosal edema. Indication for administration is typically stridor at rest, hypoxia, respiratory distress, and impending need for intubation. Corticosteroids reduce edema through anti-inflammatory action. Oral steroids are beneficial even for mild cases of croup to shorten duration. Antibiotics are typically unnecessary for viral croup. For patients treated with racemic epinephrine, there is typically a period of observation after administration to monitor for recurrence of stridor at rest.
This patient with history of asthma presented to the ED with signs and symptoms consistent with viral croup. He was treated with racemic epinephrine and steroids in the ED with recurrence of stridor, prompting admission for further monitoring. He required no further treatments and was discharged after one day. While it was reasonable to monitor him for a period of time after receiving racemic epinephrine with subsequent rebound, he was overall hemodynamically stable with no evidence of impending respiratory failure and no oxygen requirement. He did not require acute inpatient admission and could have been safely managed at a lower level of care.