Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mild hepatitis. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

The patient is a child with a past medical history notable for microtia, otosclerosis, hearing loss right ear, attention deficit hyperactivity disorder (ADHD), autism, and speech delay that presented to the Emergency Department to assess for glomerulonephritis. The patient had been diagnosed with strep throat infection and treated with Amoxicillin and Zyrtec. The patient developed flank pain and had dark urine treated with Motrin. The patient was evaluated by their pediatrician that noted a diffuse sandpaper rash suggestive of scarlet fever and microscopic hematuria by urine dip leading to the referral to the emergency department (ED). The patient's vitals were notable for Blood Pressure 113/62, Pulse 104, Temperature 36.6 degrees Celsius, Respirations 24 and room air oxygen saturation of 97%. Physical exam showed an active child in no acute distress. The patient had dry mucus membranes with normal capillary refill. Lungs were clear with normal effort. Cardiac exam was unremarkable. Abdomen exam was soft. There was no associated pain, organomegaly, distension, rebound, guarding or masses. There was bilateral flank pain noted. The patient's skin was notable for a diffuse sandpaper rash. Admitting laboratories were notable for sodium 135, potassium 3.5, bicarbonate 28, Blood urea nitrogen (BUN) 8, creatinine 0.41, glucose 93, Aspartate transferase (AST) 56, alanine transaminase (ALT) 164, bilirubin 3.4/2.6, alkaline phosphatase (AP) 430, Gamma-glutamyl transferase (GGT) 129, albumin 4, Creatinine Kinase (CK) 32, white blood cell count (WBC) 13.5 with a left shift (neutrophils 81%, no bands), hemoglobin 12.1, and platelets 423. A respiratory pathogen panel was negative. Urinalysis was notable for specific gravity 1.024, potential hydrogen (pH) 6.5 and dip + for trace protein, large ketones, large bili, trace blood, and small leukocyte esterase. Microscopic exam showed 5 white blood count (WBC), 3 red blood cells (RBC)s and no casts. The patient received one 480 milliliter (ml) normal saline bolus. Imaging included a renal sonogram that showed normal kidneys without hydronephrosis and an abdominal sonogram that showed gallbladder sludge without obstruction. 

This child appears to have a mixed picture of cholestasis and mild hepatitis with preserved synthetic function in the setting of a recent strep infection, a potential superimposed viral illness and biliary sludge. The most likely cause of the patient's waxing and waning liver tests was transient biliary obstruction as the biliary sludge demonstrated on his emergency department (ED) sonogram passed through the ductal system. The patient's initial referral to the ED for evaluation of blood noted on a urine dip turned out to be unremarkable as certainly the testing did not show glomerulonephritis and renal imaging was normal (no obstruction). 

A layered serology assessment could have been started while in the ED with follow-up and further testing in the outpatient clinic setting. Repeating his liver panel every day for several days would not add additional information and was unnecessary. The magnetic resonance cholangiopancreatography (MRCP) added no additional information to the sonogram that would have certainly detected a choledochal cyst. This patient developed symptoms after admission and his abdominal pain was likely from gastritis related to repeated Motrin dosing. Oral acid suppression would have been as effective as intravenous versions. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is not substantiated.