Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Possible human immunodeficiency virus (HIV)
exposure
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a female child that was taken to the emergency room (ED) by her mother with a request that the child be tested for human immunodeficiency virus (HIV). The mother and child lived with the mother's relatively new boyfriend, which the child acknowledged had a temper but did not touch or interact with her inappropriately. The child also denied any knowledge of psychiatric history of her mother. 

While in the emergency department, the staff received a call from the local Urgent Care that report the mother had also taken the child to that facility requesting sexually transmitted disease (STD) testing. At that time, the mother appeared to be hallucinating and was paranoid with flight of ideas. There were concerns that the child might not be safe at home, but there were no family members available to take over her care. While still in the emergency department, the mother grabbed the child and ran out, and was chased down by nursing staff. The child was returned to the emergency department and the police were contacted regarding the mother. 

The child's vital signs were appropriate for age, as was her physical examination. There were no signs of trauma or abuse. Because of concerns for inadequate guardianship, a report was filed and the child was admitted to the pediatric floor pending social services intervention and arrangements for safe discharge. Admission orders included regular diet, standard monitoring, and Social Services consultation. Routine COVID (coronavirus) testing returned positive, although the patient was asymptomatic and remained so for the entirety of her hospital stay. The patient was found to be due for vaccines (human papillomavirus [HPV], tetanus diphtheria pertussis [Tdap], and meningococcal vaccines) but because of her COVID positive status, plans were made for outpatient administration. Her biologic father was identified as a suitable guardian; she had been living with him during the previous school year, so she was safely discharged to his custody.

No, the proposed inpatient admission was not medically necessary.  The patient could have been safely managed at a lower level of care such as observation.
This child was taken to the emergency department for evaluation for possible human immunodeficiency virus (HIV) exposure as part of her mother's mental illness presentation. Initially the child was going to be discharged to her mother's care, but then the mother eloped with the child, was pursued by staff, and fell outside allowing the child to be retrieved and taken to safety back in the emergency department. At this point, the police were contacted and the mother was taken for psychiatric evaluation. The child was admitted pending appropriate placement. Following Social Service consultation, the child's biological father was identified as an appropriate guardian. The child had been living with the father the previous school year; there were appropriate support systems in place, and the father presented as an appropriate adult guardian. It was not safe or appropriate to discharge this child from the emergency department because at that time there were not appropriate adult caregivers identified. However, the patient was medically stable despite testing positive for COVID. She did not require acute inpatient admission and could have been safely managed at a lower level of care such as observation.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.