Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Headache and Low Fever after Child Birth.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female who presented ten days postpartum from vaginal delivery with epidural analgesia with severe progressively worsening headache which was described as nine out of ten (9/10), photophobia, neck pain, pain at the site of the epidural injection, and was febrile with tachycardia and leukocytosis.  The differential diagnosis included meningitis, endometritis, pelvic thrombosis, and mastitis, but at the time of admission the leading diagnosis was felt to be meningitis.  There were however considerations for endometritis and mastitis.  

The patient was admitted and given empiric intravenous antibiotics and a workup including lumbar puncture, urine and blood cultures, brain magnetic resonance image (MRI), and computed tomography (CT) of lumbar spine, abdomen and pelvis.  On hospital day #1 the patient requested to be discharged despite the concerns of the care team that she needed 24-48 more hours of observation.  By then the cerebral spinal fluid (CSF) results had come back unsupportive of the diagnosis of meningitis.  Computed tomography (CT) of the abdomen and pelvis did not reveal an abscess.  She was therefore discharged home with referral for breast engorgement on oral antibiotics.  

The facility contends that the admission was medically necessary due to concern for sepsis with temperature to 103, tachycardia, leukocytosis, left shift, severe, persistent headache, photophobia, and breast tenderness.  It cites Milliman Care Guidelines (MCG) criteria for sepsis and other febrile illness without focal infection including suspected or identified specific infection requiring hospitalization, and Milliman Care Guidelines (MCG) criteria for obstetrics/gynecology (OB/Gyn) disease including endometritis, failed outpatient treatment, postpartum complications including infections, Milliman Care Guidelines (MCG) criteria for headache, and Milliman Care Guidelines (MCG) criteria for suspected or viral meningitis.  The health plan contends that the admission was not medically necessary because the heart rate was a little faster than normal, the blood pressure was higher than normal, the temperature was a little higher than normal, absence of notes documenting unstable heart rate or blood pressure, abnormal CT scan of head, ultrasound showing bubbles in womb, or that there was infection that needed treatment in hospital, infection in the womb, excessive bleeding, and that the care could have been given in the emergency room.

Yes, the proposed inpatient admission was medically necessary.
The differential diagnosis for this patient was complex and long and included conditions that were not easily sorted out.  The list of possible diagnoses included potentially very serious conditions with both long and short term potential morbidity including post epidural/inadvertent spinal infection, meningitis, and endometritis.  Mastitis also if not promptly and adequately treated can result in serious complications such as breast abscess.  In particular, meningitis is a medical emergency and immediate empiric treatment with antibiotics is recommended.  The Milliman Care Guidelines cited by the facility includes the statement that suspected meningitis is an indication for admission.  In general, all but very mild endometritis should be treated with intravenous antibiotics as not only short term complications such as pelvic abscess, but also long term morbidity such as Asherman's syndrome can occur due to inadequate or delayed treatment.  The workup to exclude all possible causes of the headache and neurological symptoms and the fever was quite complex requiring multiple imaging modalities and there was an appropriate sense of urgency to get treatment started while the workup progressed with parenteral antibiotics that could not be given as an outpatient.  Therefore the admission was medically necessary.