Appeal type: Medical necessity
Decision: Upheld

This is a patient admitted for a possible sepsis. One day prior to admission he was seen by his pediatrician and had testing which was negative for Influenza and respiratory syncytial virus (RSV). That evening his mother noted a temperature at home of 102.6 degrees Fahrenheit (F). He had been having an occasional cough as well. Subsequently, he was taken to the Emergency Department (ED) for further evaluation. In the ED, he was not febrile and was well appearing with a normal physical exam and feeding history. Testing in the ED including a urinalysis, urine culture, cerebrospinal fluid (CSF) cell counts and culture, blood cultures and complete blood count (CBC) with differential. The white blood cell count (WBC) was 11.7. A chest x-ray showed markings that might be consistent with a viral infection. The laboratory tests did not reveal any abnormalities to indicate a specific or suspected bacterial etiology for the fever. The child was subsequently admitted for monitoring and intravenous antibiotics.
The health plan's determination is upheld.
Fever and concerns of invasive bacterial disease in children under 3 years of age has been a field of study for many years and the cornerstone of pediatric infectious disease evaluation and treatment. The assessment of a febrile infant or toddler can be a challenge. There have been numerous studies to determine clinical and laboratory criteria to stratify infants older than one month of age to determine their risk for occult bacterial sepsis. The risk of infection based upon these criteria then guide management.
"Infants younger than 90 days pose a special problem because they have an increased risk for developing a serious bacterial infection, clinical evaluation is more difficult, and a broader spectrum of invading organisms (e.g., group B streptococcus, E. coli, and Listeria monocytogenes) exists. Baker and coworkers showed the safety of managing selected low-risk infants (i.e., normal WBC count, urinalysis, lumbar puncture, and chest radiograph, and, if diarrhea was present, negative smear for fecal leukocytes) 30 to 90 days of age on an outpatient basis without antibiotics. Jaskiewicz and coworkers found the Rochester criteria (WBC count of 5000 to 15,000/mm, band count less than (<) 1500/ millimeters (mm), spun urine specimen < 10 WBCs/high-power field, stool specimen [if diarrhea] < 5 WBCs/high-power field) to have a 98.9% negative predictive value in well-appearing, previously healthy infants younger than 90 days with no focal infections. One reasonable practice guideline for managing infants with fever without source (FWS) is to hospitalize and treat all who appear toxic and all younger than 28 to 30 days. Those between 30 and 90 days of age can be managed as outpatients if they look well and the blood count, urinalysis, and cerebrospinal fluid analysis (if empiric antibiotics are to be prescribed) are within normal limits."1
The child did not have an elevated leukocyte count on his initial evaluation and also was noted to be in no acute distress and well appearing without a documented fever. He had no documented prolonged fever and no vital sign abnormalities suggesting sepsis other than one elevated temperature that occurred at home. The child did not have bradycardia at any time. He did not have any significant increase in respiratory rate suggesting sepsis. The concerns for sepsis as the justification of the admission, are not reflected in the medical records as this infant would have been considered low risk for occult bacterial infection or sepsis.