Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Abdominal pain and vomiting (Henoch-Schonlein-purpura).
Treatment:  Inpatient admission.
The insurer denied the inpatient admission.  The denial is overturned.

The Inpatient admission was medically necessary.

The patient is a previously healthy female child that had been admitted to the hospital for presumed cellulitis.  She developed swollen knees and a petechial rash, as well as poor appetite and vomiting.  She was discharged from the hospital and then returned to the ED twice and the primary care practitioner's office once with ongoing symptoms.  She presented to the ED again with persistent vomiting, abdominal pain, and migratory rash. 

The patient's vital signs included temperature 36, heart rate 85, respiratory rate 23, and 100% saturation in room air.  Examination was significant for no acute distress, moist mucous membranes, clear lungs, regular heart rate and rhythm, soft abdomen with tenderness in the left upper quadrant, and non-focal neurologic exam.  Abdominal ultrasound was negative for intussusception.  She was unable to tolerate an oral fluid challenge even after administration of Zofran.  In addition to the Zofran, she was treated with an IV fluid bolus.  Pediatric Nephrology was consulted with no recommendations.  Her constellation of symptoms was most consistent with Henoch-Schonlein Purpura.  Pediatric GI (gastroenterology) was consulted to discuss steroid management.  There was no contraindication for steroids, so she was given a dose of Solumedrol in the ED. 

The patient was admitted for failure to tolerate anything by mouth.  Admission orders included maintenance IV fluids, Tylenol as needed for pain, Zofran, possibility of ongoing steroids to be discussed with GI, regular diet as tolerated, and repeat abdominal ultrasound if severe abdominal pain.  Overnight, she continued to complain of abdominal pain, improved from the previous day.  She continued to manifest petechiae and swollen hands.  Her blood pressures were mildly elevated, but required no medications.  She continued to receive steroids with plans to wean following discharge.  Henoch-Schonlein Purpura (HSP) is an acute systemic immune-complex mediated vasculitis that occurs most commonly in children.  Gastrointestinal hemorrhage may occur when immune complexes are deposited in the small blood vessels in the gut wall.  Glomerulonephritis may occur when immune complexes affect the renal mesangium.  HSP typically follows an upper respiratory tract infection, with characteristic features including purpura, abdominal pain, and arthritis.  Symptoms may also include fever and fatigue.  Gastrointestinal complications include the following: bowel infarction, bowel perforation, duodenal obstruction, gastrointestinal hemorrhage, intestinal stricture, and intussusception.

This young girl developed signs and symptoms of Henoch-Schonlein Purpura (HSP) while hospitalized for treatment of presumed lower extremity cellulitis.  The rash and abdominal complaints developed during the admission and became progressively worse.  Although she was discharged from that hospital stay, she was taken to the ED and doctor's office multiple times for ongoing complaints.  When she presented to the ED this final time she was given the diagnosis of HSP.  She was unable to eat or drink in the ED, with persistent abdominal pain and nausea/vomiting.  There was no evidence of intussusception on ultrasound.  She was admitted for ongoing hydration and monitoring for resolution/progression of symptoms.  This child was treated in hospital, ED, and outpatient settings prior to being accurately diagnosed, with persistence of abdominal complaints.  She had failed care in all arenas.  Because of the nature of her clinical presentation (refractory vomiting, severity of abdominal pain), acute inpatient treatment was medically necessary and appropriate.  She could not have been safely managed at a lower level of care.