Appeal type: Medical necessity
Decision: Overturned

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

The inpatient admission was medically necessary.

The patient is a male child with unremarkable medical history who presented to the emergency department (ED) with ten-day history significant for fever and migrating arthralgias. He was initially seen by his pediatrician and treated with amoxicillin for seven days for otitis media. He continued to have fevers, so was then given Augmentin. He continued to have fevers as high as 106-107 with rash and arthralgias. The arthralgias affected both legs, prompting labs at the pediatrician's office with negative Antistreptolysin O (ASO) titer and Creatine kinase-MB (CKMB). 

Vital signs in the ED included temperature 98.4 spiking to 103, heart rate 125, respiratory rate 22, and blood pressure 88/55. Examination was significant for no distress, moist oral mucosa, clear oropharynx and ears, good pulses, benign abdomen, clear lungs, pain with movement and warmth of the right knee without erythema, and non-focal neurologic exam. Laboratory evaluation revealed unremarkable venous blood gas, mild anemia with hemoglobin 10.0, mild thrombocytosis with platelets 474K, unremarkable metabolic panel, negative urinalysis, elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) (17.304 and 100, respectively), negative ASO titer, Epstein-Barr virus (EBV) titers indicative of past infection, and elevated lactate dehydrogenase (LDH) 212. Electrocardiogram revealed sinus rhythm. Chest x-ray was negative. 

The patient was treated with ibuprofen, acetaminophen, and a normal saline bolus. Infectious Disease was consulted and he was admitted to the pediatric floor for further management. The differential diagnosis included juvenile idiopathic arthritis (JIA) versus rheumatic fever versus Kawasaki disease. Additional labs including mycoplasma titers were sent. By day #2, the patient was able to ambulate and denied pain in his lower extremities. Overnight, he had fever maximum 100.5. Viral panel was positive for enterovirus/rhinovirus. Cardiology was consulted to help rule out Kawasaki, with recommendations for an echocardiogram, negative for coronary artery disease. With resolution of symptoms, he was deemed stable for discharge home to follow-up with his pediatrician in one to two days. 

Fever is not unusual in children, with multiple potential etiologies ranging from mild viral infections to bacterial infections to inflammatory disorders and serious bacterial infections. Prolonged fevers, particularly in conjunction with rashes and joint complaints, broadens the differential to include such maladies as juvenile idiopathic arthritis, rheumatic fever, other rheumatologic disorders, and Kawasaki disease. Each of these conditions requires specific laboratory and diagnostic evaluation, and if positive, illness-specific treatments. 

This boy presented with longstanding history of extremely high fevers, rash, and migrating arthralgias. He was treated initially for otitis media, with an antibiotic change after the first course because of ongoing fevers. Having failed this outpatient management, he presented to the ED and underwent a comprehensive evaluation for prolonged fevers. He was admitted to continue the work-up, with consultations by Infectious Disease and Cardiology. This level of evaluation and monitoring, along with the potential for severe illness, was most consistent with acute inpatient management. Even though the evaluation did not yield diagnosis of severe illness, with viral panel revealing infection with enterovirus/rhinovirus, he had failed outpatient management and required acute inpatient admission to appropriately evaluate and manage his illness.