Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System/Other/Bronchiolitis
Treatment: Inpatient Hospital
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is partially overturned.

The patient was a female, previously healthy, who was brought to the emergency department (ED) for one hour of wheezing. She had an upper respiratory infection (URI) for three days without fever. The plan was a chest x-ray and Albuterol and steroids. The chest X-ray showed "infiltrates" in the right lung field, and after the Albuterol, the notes indicate she had improved air entry but still had wheezing. She was given Ceftriaxone in the ED and was admitted to the pediatric ward. Just before admission, her temperature was 100.9F. The admission notes states that she has been eating and drinking well without fever, vomiting, or diarrhea. On exam, she had mild suprasternal and subcostal retractions, equal and normal air entry, diffuse expiratory wheezes left more than right, and crackles on the right. Her respiratory syncytial virus (RSV), influenza, and COVID swabs were negative. She was continued on Ceftriaxone and bronchodilator aerosols. She was improved but still had some wheezes and retractions. By the second day the bronchodilators had been spaced to every 4 to 6 hours, the retractions and wheezes had resolved, and she was discharged home. The health plan denied coverage of an acute hospitalization, which is the subject of this review.

The health plan's determination of medical necessity is overturned, in whole with regard to the first hospital day and upheld with regard to the second hospital day. Care could have been provided at an alternate level of care on the second hospital day.

The bronchiolitis guideline states that observation care is indicated for tachypnea, retractions, wheezing, or unclear ability to maintain oral hydration. Acute hospital care is indicated for hypotension, respiratory fatigue (rising CO2 (carbon dioxide)), hypoxemia, cyanosis, apnea, feeding difficulty, lethargy, or the presence of an underlying chronic lung condition (e.g., cystic fibrosis, neuromuscular disease). Acute hospitalization also is indicated if the tachypnea, wheeze, or retractions are severe or persistent despite observation care.
The patient had bronchiolitis with some chest x-ray findings that showed unilateral infiltrates, so she was diagnosed with pneumonia as well. She never had an oxygen requirement. She did not have a history of fever and had only one, very low-grade temperature, of 100.9F, just prior to admission. Her laboratory values were reassuring. Given her normal laboratory values and lack of high fever, toxicity, hypoxemia, and lobar findings on chest x-ray, it was very unlikely that she had a bacterial lung infection that required antibiotics. Viral process--bronchiolitis with some lung infiltrates--was far more likely. The practice guidelines for bronchiolitis are clear about the management: in general, chest radiographs, blood work, antibiotics, and aerosol bronchodilators are not medically necessary or indicated. This patient got all four. 
Nonetheless, the patient did have tachypnea, wheezes, and retractions that were persistent despite a period of observation in the emergency department. By virtue of this, the patient met admission criteria per Milliman Care Guideline for Bronchiolitis. By the next hospital day, however, the patient had improved, and it was clear that the trajectory of the illness was favorable.