Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Henoch-Schonlein Purpura, Rash
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department (ED) with known Henoch-Schonlein Purpura with a worsening rash and inability to bear weight on her legs. She had been diagnosed the day prior by the ED. At that time, she reported intermittent abdominal pain, but the pain was not present upon return. She was an otherwise healthy child with no significant medical history except for seizure-like activity two months prior, currently under investigation. The examination was significant for no acute distress, non-toxic appearance, non-blanchable maculopapular rash with tenderness below the knee, slightly edematous ankles, and non-focal neurologic exam.  She was treated with a normal saline bolus prior to admission for further management.
Admission orders include continuous pulse oximetry, blood pressure monitoring, intravenous (IV) fluids at maintenance, regular diet, additional labs to include C-reactive protein (CRP), complement, coagulation studies, urinalysis, and stool for occult blood. Occult blood was negative, coagulation studies were unremarkable, urinalysis was essentially negative, CRP was unremarkable. Immunoglobulin A and complement component 3 (C3) and complement component 4 (C4) were pending at discharge. A computed tomography (CT) scan of the abdomen was performed and was unremarkable except for moderate stool in the colon. The child was well-appearing with symptomatic improvement. She was deemed stable for discharge home to follow-up with pediatrics and neurology (ongoing seizure evaluation). At issue is the medical necessity of an inpatient stay.

No, the inpatient stay was not medically necessary. Henoch-Schonlein Purpura (HSP) is an inflammatory condition that presents with small vessel inflammation and hemorrhage. It is characterized by petechiae and purpura. Affected patients may experience headache, fever, abdominal pain, urticaria, bloody diarrhea, joint pain. Because the small vessel inflammatory changes may affect any organ, patients may present with glomerulonephritis, joint disease, intussusception, seizures. Laboratory evaluation does not reveal coagulopathy. The cause is unknown but may be associated with increased immunoglobulin (Ig)A immune complexes, extreme food allergy, reaction to medications, or preceding viral infection. Management is supportive and my include treatment with non-steroidal anti-inflammatory agents or steroids. Those with extreme kidney involvement may require hemodialysis.
This child with recently diagnosed HSP presented with the progression of rash, pain, and swelling. The child was able to eat and drink. Laboratory evaluation revealed some minor abnormalities but nothing significantly concerning. Imaging studies were negative. She had no significant vital sign abnormalities. While it was not unreasonable to monitor the patient in the hospital for progression or resolution of symptoms, she did not have acute abdominal pain or signs of intussusception, evidence of glomerulonephritis or acute kidney injury, or evidence of central nervous system involvement. She did not require acute inpatient admission and could have been managed at a lower level of care.