Diagnosis: Shortness of Breath, Cough.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient was brought to the emergency department (ED) by his parents with a one day history of cough, fever, increased work of breathing, and scattered wheezes. He had respiratory syncytial virus (RSV) three weeks prior. He was taking fluids and solids by mouth. At triage, he was afebrile with a respiratory rate (RR) of 60 and oxygen saturation of 97% (percent) in room air. The exam showed moist mucus membranes, subcostal retractions, and a mild expiratory wheeze. He was put on an ED "asthma pathway," including decadron and albuterol, and responded to albuterol with resolution of wheezing and significant improvement in retractions. Post albuterol treatments, however, he had an oxygen saturation on room air of 89%, so he was admitted to pediatrics for supplemental oxygen. When he arrived on the pediatric floor, his oxygen saturation was 93% on room air. He had normal capillary refill and moist mucus membranes. He did not have retractions, but did have a mild expiratory wheeze. It was noted that he was "currently not requiring respiratory support, tolerating by mouth (PO) well, not requiring intravenous (IV) fluids." He was kept overnight and discharged home the next day. At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary.
The patient had mild respiratory symptoms upon presentation to the emergency department (mild tachypnea, mild retractions, bilateral wheezes), most of which had abated by the time he arrived to the pediatric floor (tachypnea and retractions gone, wheezes mild). He was not dehydrated. He did briefly have an oxygen saturation of 89% in the emergency department, but this was following albuterol administration. Transient mild hypoxemia due to ventilation-perfusion (V/Q) mismatch is common after bronchodilator therapy, and by the time he arrived on the floor, he did not require oxygen, so there was no medical necessity for the inpatient admission.