Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fevers.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male with no past medical history. He presented intermittent fevers x 3 weeks. The patient had been exposed to his two siblings, who had fevers and emesis. The patient began complaining of daily headaches, which were relieved with Tylenol/Motrin. The patient was also noted to be with emesis. His vomitus contained mostly food.

The mother also noted that the patient had been sleeping more, was napping during the day, which he did not normally do, and he wanted to be held more than usual. His mother brought him to his PMD (primary medical doctor) 7 days after initial fever and obtained a CBC (complete blood count) with WBC (white blood count) of 20 and left shift. ESR (erythrocyte sedimentation rate) was elevated to 42. The patient then went upstate for a weekend.

Three days later, repeated labs showed a CBC (complete blood count) with WBC (white blood count) of 18 with a left shift and elevated inflammatory markers. The patient had a virtual visit with Infectious disease doctor at the hospital and was told to come to the ED (emergency department).

Upon arrival to the ED (emergency department), the patient's vital signs were as follows: Temperature 100.7 Fahrenheit, BP (blood pressure): 121/80, MAP (mean arterial pressure) 93, HR (heart rate) 125, RR (respiration rate) 26, SpO2 (pulse oximetry) 97 % (percent).

When the patient presented to the ED (emergency department), he was fussy and irritable but consolable by his mother. His laboratory studies were significant for WBC (white blood count) 21.5, Neutrophils 82.8%, Hgb (hemoglobin) 10.9, HCT (hematocrit) 33.4, ESR (erythrocyte sedimentation rate) 52, CRP (C- reactive protein) 2.287. His Venous Blood Gas labs revealed the following: pH 7.314, pO2 (partial pressure of oxygen) 51.1, HCO3 (bicarbonate) 22.5, O2 (oxygen saturation) saturation 78.8.  CSF (cerebrospinal fluid) WBC (white blood count) was 63, RBC (red blood count) 274, Neutrophil 59, Lymphocyte 32, Monocyte 9, Glucose 52, Protein 51.

In light of the patient's fever and concern for meningitis, he was admitted to Pediatrics for continued monitoring and management. In the ED (emergency department), the patient had a lumbar puncture performed. He received Ketamine 22 mg (milligrams) IV (intravenous), Ceftriaxone 1470 mg (milligrams) IV (intravenous), Motrin 145 mg (milligrams). His Liver Panel was unremarkable. RVP (respiratory viral panel), UA (urinalysis) and UCx (urine culture) were unremarkable.

The patient's Lumbar Puncture was significant for WBC (white blood count) 63, RBC (red blood count) 274, Neutrophil 59, Lymphocyte 32, Glucose 52, Protein 51.  CXR (chest x-ray) was unremarkable. Echo was unremarkable. EKG (electrocardiogram) revealed sinus bradycardia. Head CT (computed tomography) with sedation was unremarkable, and no sedation issues.

The patient received ibuprofen 10 mg/kg (milligrams per kilogram), and 1 dose of Ceftriaxone 100 mg/kg (milligrams per kilogram). The patient was admitted to the pediatric floor for workup of fever.

On the pediatric floor, the patient was afebrile. The patient received 3 doses of ceftriaxone. Follow up labs showed WBC (white blood cell) count dropped to 8.7. H/H (hemoglobin/hematocrit) on discharge was 9.9/315, and platelets were 385. The patient was deemed stable for discharge home with PMD (primary medical doctor) follow up.

Yes, the Inpatient admission was medically necessary.
The patient presented with fever intermittent for more than a week; and symptoms of headache and vomiting and also not at the baseline mental status.

The patient was seen by his primary physician, and labs showed leukocytosis, WBC (white blood count) 20, and follow up WBC (white blood count) was 18 after 3 days. This clinical presentation and lab values are concerning for bacterial infection, and prompt evaluation and treatment is medically necessary for this patient.

The patient presented to the ED (emergency department) and was noted to have objective fever, and labs confirmed leukocytosis. The patient underwent extensive work up to rule out possible etiologies that may account for the symptoms and lab abnormalities - including meningitis / encephalitis, UTI (urinary tract infection), endocarditis, pneumonia, bacteremia and others.

The patient was also started on treatment with antibiotic Ceftriaxone. Results of work up obtained initially showed abnormal CSF (cerebrospinal fluid) values on analysis. The results however were not definitive for a particular infectious process, and patient required admission to ensure that the work up to evaluate for a definitive cause continues and also to ensure that patient responds to the treatment (Ceftriaxone). Managing such a patient without admission to hospital setting is not considered appropriate, as it can lead to a scenario where patient's condition can deteriorate, and the problem may not be identified. During hospital stay, the patient became afebrile and WBC (white blood count) improved to normal, and so the patient was discharged home.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.