Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Influenza, Seizures
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient has a history of Crohn's disease, autism, and febrile seizures and presented to the emergency department (ED) with a five-day history of a fever and was diagnosed with influenza four days prior to presentation. She was seen at another facility for a fever, treated with intravenous (IV) fluids, and discharged home. Neither Tylenol nor ibuprofen had been helpful. She had an episode concerning for seizure activity. After discharge, she was lethargic, with no urine output. The examination was significant for a dehydrated appearance, responsive, able to follow commands, moist mucous membranes, tachycardia, and non-focal neurologic exam. She was treated with a 500 milliliter (mL) IV fluid bolus with some improvement but was admitted for further hydration.

Admission orders included seizure precautions, IV fluids, parenteral Tylenol as needed, video electroencephalogram (EEG), and gastroenterology (GI) consultation. She did well overnight with one episode of low-grade fever. She was drinking and voiding, with no passage of stool. Tamiflu was ordered but was held per infectious disease (ID) recommendation. The video EEG was unremarkable, but magnetic resonance imaging (MRI) was ordered given her age and possible seizure in the setting of fever. Per Gastroenterology consultation, she should be evaluated for an alternative treatment to the Humira she had been treated with for two years. An immunology consultation outpatient was also recommended. She had no further seizure-like activity. MRI was planned for outpatient because it was not available during her admission. A urine culture returned negative. She continued to do well and was deemed stable for discharge. At issue is the medical necessity of an inpatient hospital stay.

The inpatient hospital stay was not medically necessary.

Influenza viral infection is a common viral respiratory illness caused by strains of influenza A or B with a broad clinical presentation for which immunization is recommended annually. The onset is typically acute, and associated with systemic symptoms such as fever, malaise, headache, myalgia, and decreased appetite. Sore throat and cough may be present from the beginning or may develop over the course of the illness. Gastrointestinal complaints may also be present, including nausea, vomiting, diarrhea, and abdominal pain. The most common complications include otitis media and pneumonia. Pneumonia may be viral or the result of secondary bacterial infection with S. aureus. Less common complications include myocarditis, encephalitis, myelitis, and Guillain Barre syndrome. Reye syndrome may occur with concomitant administration of aspirin-containing compounds. Prematurity is a risk factor for influenza-related complications, along with neurological disorders, sickle cell disease, immunosuppression, diabetes, and age under two years. Antiviral agents are available, and if administered early in the course of illness (within 48 hours), decreased duration of symptoms and likelihood of complications. Additional treatment is supportive or related to concomitant complications or bacterial infection. Annual administration of influenza vaccine for prevention is encouraged.

This female child with immunocompromise from biologic treatment for Crohn's disease presented with a persistent fever and known influenza A infection. She was given some fluids in the ED but was still symptomatic so was admitted for further management of dehydration. There was also concern for new-onset seizures because of seizure-like activity at home. Multiple subspecialists were consulted, including GI, Neurology, and ID. It was too late for Tamiflu, so it was not administered. Video EEG was performed, and arrangements were made for outpatient MRI. The mother was advised that a different biologic agent would be needed, so she was referred to her primary gastroenterologist. She responded well to hydration with improving energy and ability to drink sufficient fluid to sustain herself. While it was not inappropriate to monitor her in the hospital for further resuscitation and monitoring for seizure activity, she was overall hemodynamically stable with no neurologic symptoms, no vomiting or diarrhea to perpetuate ongoing fluid losses, and no evidence of impending sepsis. She did not require acute inpatient admission and could have been safely managed, including all consultations and diagnostic studies, at a lower level of care.