Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever, cough.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a girl with a history of premature birth complicated by spastic quadriplegic cerebral palsy, necrotizing enterocolitis, developmental delay, and seizure disorder. She was brought in by medics to the Emergency Department (ED) due to new-onset fever and cough complicated by increased fussiness and decreased activity. The patient had been recently hospitalized for septic shock secondary to acute COVID-19 pneumonia with bacterial superinfection requiring intravenous antibiotic therapy and status epilepticus requiring intubation with mechanical ventilation.

On initial presentation to the ED (emergency department), the patient was febrile (temperature of 102.8 degrees Fahrenheit), tachycardic (pulse of 139 beats per minute), and tachypneic (respiratory rate of 24 breaths per minute). On examination, the patient appeared fussy with rales and decreased air movement. Laboratory studies were remarkable for leukocytosis (white blood cell count of 15 x 109) with left-shift (neutrophils 79%), transaminitis (AST [aspartate aminotransferase] 75 and ALT [alanine aminotransferase] 85), and lactic acidosis (lactate 4.47). Chest radiograph demonstrated no acute findings. In the emergency department, the patient was administered intravenous fluid hydration and intravenous ceftriaxone.

The patient was admitted for the management of acute fever, cough, and decreased activity. The treating physician's clinical impression was emergently concerned for an acute febrile illness in the setting of recent COVID-19 pneumonia, which was complicated by acute dehydration. The treating physician's plan and treatment course for the patient consisted of intravenous fluid hydration, intravenous ceftriaxone, levetiracetam, saline nebulizers, acetaminophen as needed, blood culture, and urine culture. Once the patient clinically stabilized, achieving a gradual improvement in her acute presenting symptoms after intravenous fluid hydration and intravenous antibiotics, and the patient met the Milliman Care Guidelines (MCG) criteria for a safe discharge, the patient was discharged home with prescriptions and instructions to follow-up.

Yes, the Inpatient admission was medically necessary.
This is a medically complex patient with a history of cerebral palsy, developmental delay, and seizure who had recently been hospitalized for septic shock. As her initial presentation to the ED (emergency department) was concerning for an acute febrile illness and dehydration and she recently had life-threatening complications from infection, she remained at high-risk for life-threatening complications, and needed close inpatient monitoring as well as empiric IV (intravenous) antibiotics, IV (intravenous) fluid hydration, and infectious workup. These management and monitoring needed to be done in an inpatient setting. Therefore, she was managed at the appropriate level of care.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
This patient could not have been managed at a lower level of care due to the acuity of her presenting illness, medical complexity, recent septic shock, and need for inpatient interventions including intravenous fluid hydration, empiric intravenous antibiotics, and a timely infectious work-up, and high risk for clinical complications including persistent, uncontrolled fevers, worsening dehydration, septic shock, hemodynamic instability, multiorgan dysfunction, acute encephalopathy, recurrent seizures/status epilepticus, acute respiratory failure, acute renal failure, electrolyte derangement, arrhythmia, and even death.