Dx: Respiratory System
Tx: Inpatient Hospital
Denied: Inpatient Stay
Denial OVERTURNED in whole

The patient is a young female who presented to the emergency department (ED) with a 1 day history of cough, congestion, and wheezing. In addition, she vomited several times the day prior to admission. There was a history of fever to 102, rash, and exposure to brother with similar illness. Past medical history was remarkable for 35 week gestation and eczema.
ED vitals showed temperature (T) 99 Fahrenheit (F), heart rate (HR) 148, respiratory rate (RR) 48, and oxygen (O2) saturation of 98% on room air. Physical exam was notable for rhinorrhea, increased work of breathing with wheezing, and facial rash. The patient received ibuprofen, intravenous fluid (IVF) bolus, and albuterol nebs x 3. Respiratory syncytial virus (RSV) and influenza testing was negative. Labs showed white blood cell (WBC) count=11.5 with 47% segs and 34% lymphs, hematocrit (Hct)=36, platelets (Plt)=535. Electrolytes were normal except for low bicarb=18. Chest x-ray was obtained, and findings were consistent with acute bronchiolitis. The patient was treated with oral prednisone and albuterol/Atrovent nebs; she was still wheezing and tachypneic, so the decision was made to admit to the hospital for further management.

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

The requested inpatient hospitalization is medically necessary for this patient. This patient presented to the ED with tachypnea (RR=48), wheezing, and respiratory distress, consistent with a diagnosis of bronchiolitis. The patient was treated with prednisone and nebulizers in the ED for acute wheezing, with continued tachypnea and respiratory findings. Thus, the decision to admit to the hospital was warranted based on the acute need for continued breathing treatments and inpatient monitoring. Inpatient hospitalization was medically necessary for frequent vital sign monitoring, nebulized treatments, and respiratory support.