Diagnosis: Severe Bronchiolitis.
Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission. The denial is overturned.

The patient is a male with history of asthma who presented to the Emergency Department (ED) with belly breathing and tachypnea. He was noted to have upper respiratory infection (URI) symptoms for the past few days. He had been taken to an Urgent Care Center where he was discharged on albuterol and steroid inhalers. The patient did not have significant improvement with the above so was taken to the ED. His main complaints were cough and wheezing. Vitals signs in the ED were temperature 101 Fahrenheit, heart rate (HR) 125, respiratory rate (RR) 50, blood pressure (BP) 125/67, and oxygen (O2) saturation 95% on room air (RA). The patient was in respiratory distress and noted to be tiring. He was tachypneic with intercostal retractions. Lung exam revealed bilateral wheezing. White blood cell (WBC) count was 5.2, electrolytes were within normal limits (WNL) and chest x-ray (CXR) revealed no acute infiltrates. The viral panel was positive for respiratory syncytial virus (RSV).

The patient was admitted to the Pediatric Intensive Care Unit (PICU) for impending respiratory failure. He was treated with bronchodilators (BD) and intravenous (IV) steroids. The patient was placed on bilevel positive airway pressure (BIPAP) 10/5 with fraction of inspired oxygen (FiO2) 40%. He was found to have otitis media and placed on antibiotics. The patient slowly improved in the PICU over the next 24 hours and was weaned off BIPAP. He was transferred to the medical floor and discharged home the following day on inhalers and oral antibiotics.

Based on patients' presentation with severe bronchiolitis and impending respiratory failure requiring PICU admission and treatment with non-invasive ventilation (NIV), it was appropriate to admit this patient to the hospital. This patient had failed outpatient management and was not safe to be treated in another less intensive setting.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical Necessity is substantiated.