Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shaking
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is Upheld

The patient is a toddler male child with unremarkable medical history that presented to the ED (emergency department) with seizure-like activity, on the bed shaking, blue in the face, lasting about two minutes. He also had six-day history of fevers to 103.7, cough, post-tussive emesis, diarrhea, and congestion.
The patient's vital signs included temperature 37.4, heart rate 163, respiratory rate 28 with 95% saturation in room air. Examination was significant for no acute distress, well-appearing, dry mucous membranes, retractions, rhonchi and transmitted sounds, benign abdomen, no rashes, and non-focal neurologic exam. He was treated with a normal saline bolus. Laboratory evaluation was significant for hypokalemia (3.1), metabolic acidosis (17). Respiratory viral panel was positive for influenza A. Chest x-ray was negative. The patient was admitted for management of dehydration. Admission orders included maintenance IV (intravenous) fluids, seizure precautions, isolation, acetaminophen as needed, and routine vital signs. Over the course of his hospital stay, his oral intake improved, and the IV (intravenous) fluids were discontinued. Additional discussion led to the conclusion that seizure-like activity was more likely chills. However, he was given outpatient follow-up with Neurology. He was deemed stable for discharge on say #3.

The health plan should not cover the Inpatient Hospital Admission.

Influenza viral infection is a common viral respiratory illness caused by strains of influenza A or B with a broad clinical presentation for which immunization is recommended annually. Onset is typically acute, and associated with systemic symptoms such as fever, malaise, headache, myalgia, and decreased appetite. Sore throat and cough may be present from the beginning or may develop over the course of the illness. Gastrointestinal complaints may also be present, including nausea, vomiting, diarrhea, and abdominal pain. The most common complications include otitis media and pneumonia. Pneumonia may be viral or the result of secondary bacterial infection with Staphylococcus aureus. Less common complications include myocarditis, encephalitis, myelitis, and Guillain Barre syndrome. Reye syndrome may occur with concomitant administration of aspirin-containing compounds. Prematurity is a risk factor for influenza-related complications, along with neurological disorders, sickle cell disease, immunosuppression, diabetes, and age under two years. 
Antiviral agents are available, and if administered early in the course of illness (within 48 hours), decreased duration of symptoms and likelihood of complications. Additional treatment is supportive or related to concomitant complications or bacterial infection. Annual administration of influenza vaccine for prevention is encouraged. This male infant presented with concern for seizure-like activity, respiratory symptoms, post-tussive emesis, diarrhea. Examination was significant for dehydration. Testing revealed infection with influenza A. While it was reasonable to monitor the patient for ability to tolerate fluids and possible seizure-like activity, he was overall hemodynamically stable with no significant metabolic abnormalities, no evidence of impending sepsis or respiratory failure. He did not require acute inpatient admission and could have been safely managed at lower level of care.