Diagnosis: Difficulty Breathing
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female. Service under review is Inpatient Admission. This service was denied twice as not medically necessary.

This decision is being appealed. The patient had a recent ICU (intensive care unit) admission for acute respiratory failure due to bronchiolitis due to rhino/enterovirus, and presented to ER (emergency room) with respiratory distress, wheezing, retractions, tachypnea, tachycardia. Her VBG (venous blood gas) and CBC (complete blood count) were normal. Her CXR (chest x-ray) was unremarkable. She tested positive for rhinovirus.

The patient was given inhaled bronchodilators, systemic steroids, systemic bronchodilators, and IV (intravenous) fluids. Afterwards the patient's work of breathing decreased, lung sounds improved but wheeze not resolved, less tachypnea, still mild retractions.

The reason for admission was documented as hypoxemia, despite normal SpO2 (pulse oximetry) (note states SpO2 was 94-100% on room air). She was admitted to inpatient unit, remained on room air, given albuterol every four hours, and discharged after one night in the hospital.

No, the inpatient admission was not medically necessary.

The proposed treatment was not medically necessary, using applicable and generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards, and associations. The stated reason for the hospitalization was need for supplemental oxygen. Hypoxemia is generally defined as oxygen saturation less than 92% (percent) on room air (MCG [Milliman Care Guidelines]), which this patient did not have. There were no other reasons for the admission. The patient did not have hypotension, elevated PCO2 (partial pressure of carbon dioxide), cyanosis, apnea, tachypnea wheeze or retractions that are severe or persistent after observation care treatment, inability to maintain oral hydration, feeding difficulties, or lethargy.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.