Diagnosis: Respiratory Syncytial Virus (RSV)

Treatment: Inpatient admission, monitoring

The insurer denied the inpatient admission. The denial was upheld.

This is an infant who presented with fever of 102.0 F, worsening cough for three days, nasal congestion, and difficulty breathing. The documentation of the Emergency Department (ED) examination was contradictory. The chest was said to be clear to auscultation, but congestion was heard. There was no tachypnea, no wheezing, no retractions, nor increased work of breathing. A test was positive for Respiratory Syncytial Virus (RSV). A chest-x-ray was unremarkable. Following admission, the History & Physical (H&P) stated: "Chest: Clear, equal breath sound bilaterally without rhonchi, crackles, or wheezes. Normal work of breathing. No retractions. Good air entry bilaterally."

Subsequent physician notes stated the patient's chest was clear with equal breath sounds and no retractions. The patient was documented as having good oral intake and urinary output, no respiratory distress, with intermittent fevers. A blood culture result was pending. The disposition plan stated: "Discharge today if remains non-toxic appearing, good p.o. and urine output, stable respiratory rate and maternal concerns about intermittent fevers are completely addressed". The patient remained hospitalized until the next day. The blood culture remained with no growth. The infant was in no distress and was discharged to home.

This infant presented with an RSV infection that mainly affected the upper airway. There was no need for oxygen or intravenous (IV) fluid. PO intake and urine output were adequate. Inpatient criteria were not met. Observation criteria (e.g., MCG: Bronchiolitis Observation Care: Observation) is appropriate for patients whose situation includes 1 or more of the following: Clinical response to outpatient therapy uncertain.

The denial of the inpatient admission was appropriate. The patient met the MCG: Bronchiolitis Observation Care: (Observation) criteria. The carrier's denial of coverage for inpatient services is upheld. The medical necessity is not substantiated.