Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Adenoidal Hypertrophy

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

The patient is a male with a history of asthma, sinusitis, and tonsillitis. He presented to the emergency department (ED) with complaints of a fever. He had a COVID (coronavirus) swab that was negative. The patient was prescribed amoxicillin for 2 weeks. His symptoms initially improved. Two days later, he spiked a fever and was started on a 4-day course of prednisone. Once again, his fever spiked. He returned to the ED per the recommendation of his treating provider. The patient was in moderate distress. The patient's mother reported that the patient had spiked a fever as high as 103 for the past night. The physical exam findings of the patient noted erythematous throat with large tonsils. The vital signs of the patient were documented as temperature 98.4 degrees Fahrenheit (F) and one spike of 101.4 (responded to Motrin), respiratory rate of 19-22, pulse rate of 99, and oxygen saturation of 98% (percent) on room air. The lab results of the patient noted white blood cell count of 14.0, red blood cell count of 4.24, hemoglobin 11.7, hematocrit of 36.0, erythrocyte sedimentation rate of 41.0, sodium 137, potassium of 3.9, chloride of 106, blood urea nitrogen of 11, creatinine of 0.3, C-reactive protein 9.25, total protein is 7.0, and albumin of 3.4. The patient was admitted for further evaluation of the throat infection. The patient's mother reported that the patient had a history of 3-5 episodes of tonsillitis per year and multiple sinusitis episodes, most of them required antibiotics for treatment. The patient also complained of bilateral knee and leg pain. Infectious Disease and Otolaryngology were consulted over the case. He had longstanding history of frequent upper respiratory infections and tonsillitis that was concerning for underlying immune disorder. A chest x-ray of the patient's neck and soft tissues revealed adenoidal hypertrophy. He was started on intravenous (IV) vancomycin every 6 hours, ceftriaxone every 12 hours, and clindamycin every 8 hours. The patient's condition improved after treatment. He was discharged with a recommendation to complete a 7-day course of clindamycin, cefdinir, and Culturelle.

Per the referenced guidelines, admission for sepsis or other febrile illness without focal infection is appropriate in patients who are hemodynamically unstable, had bacteremia, have hypoxemia, have persistent tachypnea, have altered mental status, have failure of outpatient treatment, and in patients who have signs of poor perfusion. The patient has a history of asthma and recurrent tonsillitis and sinusitis who presented with severe, persistent fever, sore throat, enlarged "kissing" tonsils, concern for sleep apnea, cough, and odynophagia. He was found to be febrile and tachycardic. He had leukocytosis, and elevated inflammatory markers. The patient had complied with but failed outpatient therapy including oral antibiotics and prednisone. The patient continued to spike fevers at home 103.7 F. His maximum temperature in the hospital was 102.2 F despite all interventions. Consultations with Infectious Disease, Hematology and Ear, Nose, and Throat (ENT) were obtained. The patient was dehydrated even as an inpatient (urine specific gravity > 1.035 and only two recorded urinations in 24-hour period). He required peaks / troughs to be recorded while on IV vancomycin as an inpatient. He had failure of lower level of care and meets Milliman Care Guidelines (MCG) Guidelines for admission. Thus, the denial of coverage for the inpatient hospital admission is overturned.

The healthcare plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The inpatient admission is considered medically necessary for the patient.

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical necessity is substantiated.