Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Influenza B.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented with a three-day history of a fever and cough. His maximum temperature (Tmax) was 102 degrees Fahrenheit, not relieved by Tylenol. Four (4) days before admission, the patient was tired appearing but afebrile. The following day he developed a fever that was not relieved by Tylenol accompanied by a dry cough. The patient was taken to an urgent care center, tested positive for Flu B, and was stared on Tamiflu. He had his first dose the day before admission but vomited 30 minutes after. The fever continued to persist despite Tamiflu. He also started to breathe faster since the day prior and sounded congested. There was no diarrhea. Decreased hydration and by mouth (PO) fluids since two days ago but making normal urine were reported. Sick contacts were denied.
In the emergency room (ER), the patient was initially febrile to 100.8 degrees, with tachycardia to 160. Otherwise, he was breathing comfortably on room air. He was given a dose of Motrin, but the fever persisted and was up to 101.8 degrees 2 hours later for which he was given a dose of Tylenol, and then he eventually defervesced. On exam, he was tired, appearing with decreased activity, and had signs of mild dehydration with capillary refill around (~) 3 seconds. He received two normal salines (NS) boluses and was then started on intravenous fluids (IVF) at one time (x) maintenance. His fever returned a few hours later, and he was given another dose of Tylenol. A complete blood count (CBC) was significant for a low hemoglobin and hematocrit (H/H) of 9/32 but otherwise within normal limits (WNL) with no leukocytosis. The basic metabolic panel (BMP) showed bicarbonate of 20 and potassium (K+) of 5.0 but was otherwise normal. He was positive for Flu B and negative for respiratory syncytial virus (RSV), and Flu A. Blood and urine cultures were sent. A chest x-ray (CXR) was unremarkable. The admission exam documented the child to be tired appearing, sleeping, and fussy. He was breathing comfortably with no signs of respiratory distress, no use of accessory muscles, capillary refill ~3 sec. He received one dose of Tamiflu and later in the evening, the patient started to become tachypneic with mild retractions and head bobbing. He was placed on 1 liter (L) of oxygen via nasal cannula (NC) and was admitted to the pediatric floor for IV rehydration in the setting of Flu B infection. On the floor, the patient remained afebrile and vital signs were stable. The patient was weaned to room air over the course of the day and tolerated this well without any desaturations. IVF was discontinued as he maintained good PO intake and continued to make good urine output. On the physical exam, the patient looked much improved and not concerning for dehydration with clear lung sounds. On hospital day #2, the patient developed a fever overnight that persisted all night and was not relieved by Tylenol. He defervesced later in the morning. Respiratory wise he remained stable. His mother felt comfortable taking him home. He was deemed stable for discharge with anticipatory guidance and return precautions. He was instructed to follow up with his primary medical doctor (PMD) in 1-2 days.
At issue is the medical necessity for an inpatient level of care.

The requested health service/treatment of inpatient stay was not medically necessary for this patient. This infant presented with a fever and cough after being diagnosed with Influenza B the day prior. His admitting diagnosis was dehydration in the setting of influenza B infection. Neither of these conditions, in this patient, were serious or severe enough at presentation or throughout the hospitalization to require an acute inpatient level of care. He did not meet any criteria for inpatient admission for dehydration nor for respiratory illness. He was noted to have some mild retractions and he was placed on supplemental oxygen (O2). This patient did not exhibit any documented hypoxia. Also, in the registered nurse (RN) notes, there is documentation that, after suctioning the patient's respiratory status significantly improved. He had no documented tachypnea, no PO intolerance, no markedly abnormal laboratory studies. He was noted initially to have ~3-second capillary refill; there is no reported reassessment after the completion of his 2 NS boluses. The patient's mother could have been instructed on how to use saline and suction, and this child could have been monitored closely at a lower level of care after proper rehydration with NS boluses and being observed in the ER. There was no documented hemodynamic or respiratory instability or failure to respond to ER management. He had received 2 boluses of normal saline in the ER, but prior to that, laboratory studies that were obtained did not support dehydration. There is no mention of PO intolerance. By the next morning, the child was tolerating breastfeeds well. The patient had an accompanying Influenza B infection with a history of fever and cough. The chest x-ray (CXR) was read officially as negative. There was no mention of significant respiratory distress or hypoxia. Laboratory studies at admission were not concerning. There was no elevation in inflammatory markers. While in the hospital, the child did not receive highly skilled or specialized care. Inpatient admission was not medically necessary for this patient.