Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever and cough. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

The patient was a child evaluated in the emergency department (ED) with 3 days of fever, decreased oral intake as per mom, and respiratory issues consisting of cough and nasal congestion. The patient vomited twice. The emergency department (ED) summary evaluation included possible pneumonia. The child received 2 fluid bolus of normal saline, and intravenous (IV) vancomycin, ceftriaxone and Tylenol for fever.
On physical examination heart rate was 169 beats per minute, Oxygen saturation on room air was 98%, respiratory rate was 32 breaths per minute, 25% percentile for weight. Breath sounds were normal, good capillary refill, no retractions and normal behavior. 
Laboratory results were white blood cell (WBC): 3.9, absolute neutrophil count (ANC) 2039, hemoglobin/hematocrit (H/H) 12/35, elevated monocytes, blood urea nitrogen (BUN) 18, creatinine 0.4, blood gas Po2 74, pH 7.318, normal Liver Function Test Screen.  Chest X-ray showed small airway disease such as bronchitis or bronchiolitis. 

Despite normal examination, diagnosis listed as pneumonia, and rule out sepsis based on fever, tachypnea and tachycardia. Sepsis protocol initiated as per emergency department (ED) policy. Noted is chest X-ray without infiltrate, but signs of clinical pneumonia. (These signs are not documented anywhere). The plan is to admit to pediatrics and discontinue sepsis protocol. BioFire panel is positive rhino/enterovirus.  Two fluid boluses were given however he was not reported to have dry mucous membranes and there were no ketones in the urine. 

The child was admitted to the floor. Day 2 notes report he was well hydrated, and reason for admission is rule out respiratory sepsis.  He was given antibiotics, but no discussion is available as to why these needed to be continued if the thought was that this was a viral illness and not bacterial. At the time of floor transfer he was well hydrated, moist mucous membranes and had a normal lung exam. Intravenous (IV) fluids were stopped. His blood culture was negative. He developed a rash on his face and torso. His lung exam continued to be normal. Intravenous vancomycin was stopped when the rash was noted, however ceftriaxone was continued. His additional labs included a normal C-reactive protein (CRP), unremarkable complete blood count (CBC), and metabolic panel.  
On day of discharge the notes report the rash, normal lung exam, and diagnosis of roseola. 

There was no wheezing, or retractions. There was normal pulse oximetry, no other organ involvement, unremarkable urinalysis, and chest X-ray that does not show any consolidation/pneumonia. He is not neutropenic and has a normal C-reactive protein (CRP), as well, making it unlikely that he has either sepsis or pneumonia. 

The BioFire respiratory viral panel was sent and consistent with rhino/enterovirus. This case represents a significant departure from AAP (American Academy of Pediatrics) guidelines and standard of practice. 
The diagnosis of respiratory viral sepsis depends on two steps: one step is the diagnosis of sepsis using the SOFA (Sequential Organ Failure Assessment) score, includes respiratory rate-corrected for fever, altered mental status, systolic blood pressure, and the other important and challenging step is identifying the cause of the sepsis as a respiratory virus. This child does not meet the criteria for respiratory sepsis. 

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 the inpatient admission is not substantiated.