Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System
Treatment: Inpatient Hospital
The insurer denied: Inpatient stay
The denial is: Upheld in whole

The patient is a male twin that presented to the emergency department (ED) with two-day history of cough and cold symptoms and one-day history of increased and persistent crying. His mother was sick at home with the flu. He had a low-grade fever to 100.0 and decreased feeding but no respiratory symptoms, vomiting or diarrhea. Vital signs included temperature 97.8 to 100.3 (rectal), heart rate 131, respiratory rate 32, and 100% saturation in room air. Physical examination was significant for no distress, mildly sunken anterior fontanelle, moist oral mucosa, clear lungs but with mild pulling, benign abdomen, and non-focal neurologic exam. Chest x-ray was obtained and was unremarkable. Rapid influenza testing was positive for influenza B. Laboratory evaluation including complete blood count (CBC), metabolic studies, and venous blood gas was overall unremarkable. He was treated with a normal saline bolus followed by maintenance fluids (with subsequent two wet diapers), Tylenol, and Tamiflu. He tolerated about four ounces of formula while in the ED had one small episode of vomiting. He was admitted for further management of dehydration. Admission orders included intravenous (IV) fluids, ad lib feedings, and Tamiflu. He drank about one ounce overnight with one episode of post-tussive vomiting. He continued to improve, with no further episodes of vomiting, tolerating his morning feeding. He was deemed stable for discharge to complete his course of Tamiflu and follow-up with his pediatrician in one to two days. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

No, inpatient stay was not medically necessary for this patient.
Influenza viral infection is a common viral respiratory illness caused by strains of influenza A or B with a broad clinical presentation for which immunization is recommended annually. Onset is typically acute, and associated with systemic symptoms such as fever, malaise, headache, myalgia, and decreased appetite. Sore throat and cough may be present from the beginning or may develop over the course of the illness. Gastrointestinal complaints may also be present, including nausea, vomiting, diarrhea, and abdominal pain. The most common complications include otitis media and pneumonia. Pneumonia may be viral or the result of secondary bacterial infection with staphylococcus (S.) aureus. Less common complications include myocarditis, encephalitis, myelitis, and Guillain Barre syndrome. Reye syndrome may occur with concomitant administration of Aspirin-containing compounds. Antiviral agents are available, and if administered early in the course of illness (within 48 hours), there is a decreased duration of symptoms and likelihood of complications. Additional treatment is supportive or related to concomitant complications or bacterial infection. Annual administration of influenza vaccine for prevention is encouraged.
This patient presented with poor oral intake, irritability, and cough, with signs of dehydration on exam. His mother was ill with the flu and had just started a course of Tamiflu. The patient was treated with a fluid bolus in the ED, but because he failed an oral challenge, was admitted for further hydration and monitoring. While it was medically necessary to continue monitoring the patient until he was able to drink enough to sustain himself, he was overall hemodynamically stable with no evidence of sepsis or impending respiratory failure. He did not require acute inpatient admission and could have been safely managed at a lower level of care status.