Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ears/Nose/Throat. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is overturned. 

The patient is a male with a complex medical history who presented with fever and neutropenia. 
His past history is significant for a premature birth, asthma, and a history of cardiac arrest secondary to group B strep sepsis. He also has a history of ventricular tachycardia as well as speech delay. He was in his usual state of health until the day prior to presentation when his mother noted a bump behind his right ear. It was tender to the touch, and he was acting more tired than usual. His temperature was 102 Fahrenheit (F) at that time, and he was brought to the emergency department for evaluation. 

In the emergency department he had a temperature of 100.2F. His physical examination was significant for oropharyngeal exudate with injected tonsils, and a 2 centimeter (cm) soft mobile lymph node on the right superior posterior cervical chain. He also had 2-3 smaller lymph nodes in the left posterior cervical chain. An electrocardiogram (EKG) was obtained which revealed sinus tachycardia. A complete blood count revealed a white blood count of 4.0 with an absolute neutrophil count of 300. His sodium was 130 and C-reactive protein was 1.1. Blood cultures were sent, and he was started on intravenous cefepime as well as maintenance fluids. The hematology/oncology team was consulted and recommended inpatient admission for ongoing treatment for fever and neutropenia. 
In the hospital, he was continued on intravenous cefepime, and his complete blood count was checked daily. Cardiology was consulted and followed him throughout the admission. He continued on his home verapamil and remained in sinus rhythm. His blood cultures remained negative during the admission, and on the second hospital day his absolute neutrophil count had improved to greater than 500. Since he had been afebrile for more than 48 hours, he received a dose of ceftriaxone and was felt to be stable for discharge to home with follow-up as an outpatient. He was also cleared for discharge by the pediatric hematology/oncology service. 

The medical necessity for the inpatient stay is the subject under review. 
The health plan's determination is overturned. 
The requested health service/treatment of inpatient stay was medically necessary for this patient. 

This is a patient with a complex medical history who presented with fever and neutropenia. His temperature had gone up to 102 F, and his absolute neutrophil count was initially only 300. Due to the risk of serious infectious complications for patients with febrile neutropenia, and particularly serious bacterial infection, he required inpatient admission for treatment with parenteral antibiotics while cultures were pending, as well as intravenous fluids and monitoring. 

An increased risk of bacterial infection occurs with absolute neutrophil count (ANC) less than (<) 1,000, and the risk increases with lower levels of neutrophils. This patient had an initial ANC of 300, making inpatient admission appropriate for treatment and intensive monitoring while cultures were pending. 
The decision-making at the time of admission for this patient was consistent with his age, his complex medical history, and the presence of fever and neutropenia necessitating parenteral treatments and close monitoring for potential deterioration in status.