Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever, nasal congestion and cough
Treatment: Inpatient admission

The inpatient admission was medically necessary.

The patient is a male infant that presented to the emergency department (ED) in the early morning with fever to 102.2. He also had one-day history of nasal congestion, runny nose, and cough. He was born at term via vaginal delivery. His mother was positive for group B Strep (GBS) and did not receive antibiotics four hours prior to delivery. 

Vital signs included temperature 39.2, heart rate 176, and respiratory rate 46 with 98% saturation in room air. Examination was significant for no distress, flat anterior fontanelle, dry nasal crusting around bilateral nares, moist mucous membranes, clear tympanic membranes, regular rate rhythm, clear lungs, cough with no difficulty breathing or retractions, and non-focal neurologic exam. He was placed in observation status in the ED pending results of laboratory studies. Laboratory evaluation was significant for white blood cell (WBC) count 10.14K with 33.7% neutrophils, negative urinalysis, negative respiratory viral panel, C-reactive protein (CRP) 10.86, and procalcitonin 0.55. There were multiple attempts at lumbar puncture, all with bloody drainage. The patient was given a dose of Tylenol, normal saline bolus, and ceftriaxone prior to admission for continued management. Admission orders included continued ceftriaxone, monitoring of culture results, and anti-pyretics. 

Upon admission, lumbar puncture was again attempted (15 hours after antibiotics) with bloody cerebrospinal fluid (CSF) submitted for cell count, culture, gram stain, and meningitis/encephalitis polymerase chain reaction (PCR). Chest x-ray was negative. The patient was started on intravenous (IV) fluids for decreased feeding, although he continued to breastfeed. Repeat labs included decreasing inflammatory markers, and cultures remained negative. Respiratory viral panel was repeated and was again negative. His last fever was low-grade, 38.2 in the morning two days after being admitted. He remained for the duration of the hospital stay, and upon return of the meningitis/encephalitis panel negative, antibiotics were discontinued and he was discharged home. 

This patient presents a particularly complicated situation, one that has not yet yielded specific recommendations. When he presented to the ED, he had high fever and the mother had history of inadequately treated positive GBS. Most clinicians and risk grading systems would consider him to be at high risk for serious bacterial infection, necessitating full septic work-up. This would include lumbar puncture, followed by a broad-spectrum antibiotic or combination of antibiotics pending culture results. In the ED, there were four attempts at obtaining CSF from lumbar puncture, and none were successful. Inflammatory markers (CRP, procalcitonin) were elevated, with concern for serious bacterial infection. Prior to admitting the infant, the ED administered a meningitic dose of ceftriaxone despite the lack of CSF culture. Fifteen hours passed before a successful lumbar puncture was performed, with enough CSF to send for culture. Typically, other features of the CSF (cell count, glucose, protein) can be used in determination of likelihood of meningitis. In this case, there was insufficient fluid to obtain glucose and protein values, and the fluid was bloody, making cell count somewhat difficult to interpret. Gram stain, however, was negative, and a sample was sent for meningitis/encephalitis (ME) PCR testing. According to the current recommendations, with antibiotic pre-treatment and no other etiology for high fever identified (negative respiratory viral panel twice, negative chest x-ray, negative urine), it was medically necessary and appropriate to continue treatment pending results of both cultures and ME testing. The full duration of the hospital stay was medically necessary.