Diagnosis: Adenovirus and Enterovirus.
Treatment: Hospital Admission.

The insurer denied coverage for hospital admission.
The denial is upheld.

This infant male with no significant past medical history. He presented to the emergency room (ER) with complaints of shortness of breath (SOB) and a cough. In the ER, temperature and heart rate were elevated. The physical examination was significant for subcostal retractions, course lung sounds, and expiratory wheezing. Intravenous (IV) fluids were given, and labs were collected. White blood cell (WBC) count was elevated. The chest x-ray (CXR) revealed no significant findings. The rapid viral panel (RVP) revealed adenovirus and enterovirus. He was given Ceftriaxone, steroids, and nebulizers. The patient was admitted to the pediatric intensive care unit (PICU) for acute respiratory failure. Albuterol was given and weaned. The patient was initially placed on high flow oxygen and then weaned to nasal cannula. He was transferred to the floor. Albuterol weaning continued and steroids were given. The patient's condition improved, and he was discharged.

The patient could have been managed at a lower level. There was no need for repeated Magsulfate, no need for continuous nebulizers for prolonged time, no need for terbutaline drip or continuous steroids. The patient's saturation was 90 percent at its' lowest. If one were to assess the asthma severity such as Pediatric Asthma Severity Score or Pediatric Respiratory Assessment Score (PRAM), the score would indicate that patient needed only at lower level of care such as observational status or outpatient. Furthermore, the chest x-ray revealed was normal which is expected. Also, there was no underlying medical conditions such as chronic lung disease or congenital heart disease. There was also no need for BiPAP (Bilevel Positive Airway Pressure). There was no need for pressors and no need for positive pressure ventilation. The Pediatric early warning score (PEWS) documented by the nursing was always 0 which is perfect score and predicted uneventful course. If one were the examine the PRISM (Pediatric Risk of Mortality) score, that would be low and desirable too; the PRISM score incorporates, various clinical parameters and lab parameters (systolic BP (blood pressure), acid base values etc.) to synthesize a score system used in Pediatric ICU [intensive care units] to control for severity of illness or injury when comparing patients within and between ICUs. The Hospital course was suggestive of rapidly improving clinical picture.
Due to all the above reasons, the reviewer deems it that the patient only required observational status care.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the hospital admission is upheld. Medical Necessity is not substantiated.