Diagnosis: Bronchiolitis
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

The patient is a toddler with history of 3 days of fever and 2 days of coughing. On the day prior to the admission the child was having difficulty breathing and was taken to the Emergency Room (ER). In the ER the child was treated with Combivent inhalation therapy and prednisone. The child tested positive for the respiratory syncytial virus (RSV) and was discharged home from the ER to continue taking albuterol every 4 hours. Despite this treatment the child continued to have difficulty breathing and coughing so the mother decided to return with the child to the ER for additional treatment.

There is a past medical history significant for a Coronavirus (COVID-19) infection in and a previous respiratory illness which required treatment with oxygen with a High Flow Nasal Cannula (HFNC). Following this illness, the pediatrician had prescribed daily inhalation treatment with budesonide, but the mother stopped administering this treatment 2 weeks prior to this illness.

In the ER, the patient was noted to be in respiratory distress with subcostal and intercostal retractions. On physical examination there were coarse breath sounds heard bilaterally. The child was treated with an intravenous (IV) bolus of normal saline because there had been a decrease in oral intake and urine output. The child was again treated with methylprednisone and albuterol in the ER. A chest X-ray demonstrated increased peribronchial lung markings. Since the child had been treated in the ER the day prior to returning to the ER and failed outpatient management with bronchodilator and steroid therapy the decision was made to admit to the hospital for continued treatment with albuterol every 2 hours and continue IV fluids with a diagnosis of bronchiolitis.

The patient was treated appropriately in the ER for a respiratory illness with fever, coughing, and persistent respiratory distress with decreased oral intake and urine output. The patient had been seen in the ER the day prior to the admission and was diagnosed with RSV viral illness. When the child failed outpatient treatment with prednisone and albuterol every 4 hours the mother returned to the ER. Since the child had respiratory distress with subcostal and intercostal retractions the decision to admit for continued albuterol every 2 hours was consistent with the standard of care for a toddler with bronchiolitis. The child could not have been discharged safely since the symptoms had failed to improve with outpatient therapy.

Based on the above, the insurer's denial must be overturned. The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient. Medical necessity for the inpatient hospital admission is substantiated.