Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Viral upper respiratory infection 
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


The patient has a past medical history of coronovirus (COVID). His mother states the patient had rhinorrhea and sneezing for the past 2 weeks. Four days prior to presentation, the patient had chills, a cough, nasal congestion and a rectal temperature of 103 degrees Fahrenheit for which he was not given medications but his mother gave him a luke-warm bath. The mother denies that he had vomiting, diarrhea, recent travel or sick contacts. As per mother, the patient has constipation but on the day prior he had one episode of loose watery stool with no blood or mucus. His mother brought him to the emergency room (ER) 2 days prior and he was discharged home with supportive care. He had negative respiratory syncytial virus (RSV), Flu and COVID testing at that time. He continued with the symptoms and had decreased oral intake and decreased urine output which is why his mother brought him back to the ER.
In the ER, his vital signs upon presentation included heart rate (HR) 182 (febrile), respiratory rate (RR) 26, and oxygen saturation (O2 sat) 97%. On exam, he was noted to have impacted cerumen, congestion, rhinorrhea. He was febrile and described as tachycardic and tachypneic. He had no nasal flaring, no mention of retractions, no wheezing, rhonci or rales. He was managed with an acetaminophen suppository due to a temperature of 104 degrees Fahrenheit (F), ibuprofen and sodium chloride (NaCl) 0.9%, intravenous fluid (IVF) bolus.
A urinalysis (UA) revealed 1.025 specific gravity (SG), 100 protein, 40 ketones. A comprehensive metabolic panel (CMP) revealed sodium (Na) 133, potassium (K+) 5.9, and aspartate aminotransferase (AST) 63. The white blood cell count (WBC)was 14.6. The initial plan per the ER physician was to place the patient in observation for dehydration, and hold antibiotics for now.
He was admitted to the pediatric floor for further management of a viral upper respiratory infection and low urine output. His admission assessment documented breathing on room air with an oxygen saturation greater than (>) 95%, tolerating a diet but with decreased oral intake. He was noted to have developmental delay. He was admitted for monitoring and a requirement of IV hydration. The plan upon admission was for intravenous fluids (IVF) at maintenance, regular pediatric diet and an as needed (PRN) antipyretic. On the admission exam, the patient had nasal congestion and rhinorrhea noted. On the pediatric floor, the patient continued to have a high grade fever throughout the first day of admission so he was started on IV Ceftriaxone. He continued to have poor by mouth (PO) intake so he continued to receive 1 times (x) maintenance IVF. On the second day of admission, he still had a fever spikes with a maximum temperature (Tmax) of 104.2 degrees. His oral feeding tolerance improved but was still less than normal. His PO intake started to improve towards late evening on the second day of admission and by day 3 of admission, he was able to tolerate regular feeds. The patient had good urine output throughout the admission. He was advised to follow up (F/U) with the primary medical doctor (PMD) in 3-5 days. He was referred to an early intervention program for developmental delay.
At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was not medically necessary for this patient.
The patient did not require a high level of care or intensive therapies. He was placed on oral antipyretics as needed, IVF and was later started on once daily IV antibiotic coverage as the fever persisted for the first 24-48 hours of admission. He did continue to have a fever but fever alone is not criteria for inpatient admission. He was never in respiratory distress or tachypneic as a result of his upper respiratory infection nor was he hypoxic. The radiologist read the chest x-ray (CXR) as negative. He had no documented signs of dehydration as a result of his poor PO intake. His laboratory studies were not indicative of serious bacterial infection at the time he was admitted. His electrolyte panel was not critical. He could have received management in the ER along with education on signs and symptoms of when to return to the ER along with close follow up.
Per the Milliman Care Guidelines (MCG) Sepsis and Other febrile Illness, without Focal Infection, Pediatric, the patient did not have hemodynamic instability, fever greater than (>) 103.1 degrees that could not be reduced by outpatient, emergency treatment or observation care, altered mental status that was severe or persistent, seizure, fever for > 5 days, finding that prompts suspicion or diagnosis of specific infection requiring hospitalization, failure of outpatient treatment, metabolic disorder that is severe or persistent, toxic clinical appearance that persists without identified cause, IVF required rather than oral rehydration to replace significant outgoing losses, supplemental oxygen or respiratory treatments for over 24 hours that are performable only in acute inpatient setting, parenteral antimicrobial regiment that must be implemented on inpatient basis, strict or protective isolation needed or other condition, treatment or monitoring requiring inpatient admission. He did not meet criteria for an inpatient stay.