Appeal type: Medical necessity
Decision: Overturned

This is a patient who presented to the hospital with fevers and sweats for five days. His temperature reached 38 or 39 degrees Centigrade (C); 2 days before coming to the hospital, he was seen by his primary care physician and prescribed Augmentin. After taking the Augmentin, he started to have nausea, vomiting, diarrhea, and epigastric pain. He denied chest pain or shortness of breath. 

On exam, the patient was awake alert and oriented times (x) 3, lungs were clear, and the cardiac exam was normal. The abdominal exam showed no tenderness, good bowel sounds, and no pulsating masses. Laboratory studies showed a white blood cell count of 18,000 with a hemoglobin of 13.8 and platelets of 409. The chemistry panel showed a normal potassium and sodium, blood urea nitrogen (BUN), and creatinine were normal as well. Liver function tests (LFTs) were unremarkable. Influenza A and B tested negative. The urinalysis showed a negative leukocyte estrace, positive ketones, and 0-2 white blood cells. 

A chest x-ray showed clear lungs. The patient was admitted to the hospital, and an extensive workup was initiated, including blood cultures, a urine culture, stool studies with parasitic smear and human immunodeficiency virus (HIV) testing as well as a hepatitis panel. An ultrasound of the abdomen was also ordered. 

The patient reported recent travel to Israel, two months before this presentation.
The following day the patient was experiencing vomiting. He remained febrile with a maximum temperature (T-max) of 102.4 degrees Fahrenheit. The mucous membranes were described as moist; the rest of the exam was unremarkable. An infectious disease consultation was requested, and the patient was treated with Zofran for nausea and vomiting. The laboratory studies showed a white blood cell count of 14.8 on this day, which was improved from 18,000. The abdominal ultrasound showed no gross abnormalities. Liver function tests remained stable. BUN and creatinine remained in the normal range. The diarrhea subsided, and so did the abdominal pain. 

The infectious disease specialist evaluated the patient and found out new information about the patient's recent travel to Israel. There were a lot of mosquitoes around; he was bitten a lot during the trip experiencing some traveler's diarrhea, which subsided without antibiotics during the first week of July approximately one month before this presentation. Also, rickettsial titers were sent, as the patient had a right posterior leg eschar, and the patient was started on doxycycline empirically. 

The following day, the patient has less diarrhea and still some nausea. Reglan was added as needed for the treatment of nausea. Clostridium (C) difficile came back negative. Imodium was started for diarrhea treatment. Per the infectious disease consultant, the etiology of the patient's symptoms was unclear. Blood cultures were negative; a urine culture was negative, stool cultures were negative. The patient was started on intravenous (IV) ceftriaxone in addition to the IV doxycycline; he continued to experience febrile episodes with a T-max of 101.7 degrees. The abdomen remained benign, and the patient was given proton pump inhibitors. 

The patient was feeling better, with no further diarrhea, and nausea was improved. Protonix was stopped. T-max was 101.1, but he remained hemodynamically stable. Repeat laboratory studies showed a white blood cell count of 16.8 with a hemoglobin of 12.7. Electrolytes and renal function remained normal. Blood cultures remained negative. The infectious disease specialist contemplated obtaining a computed tomography (CT) scan of the chest abdomen pelvis with contrast if the patient continued to have fevers and had persistent leukocytosis. 

The patient again spiked a fever of 101.4 degrees and required Zofran for nausea. The white blood cell count, however, improved down to 10.9. A CT scan of the abdomen and pelvis was performed, which showed moderate to severe bilateral upper, right middle and lower lobe alveolar opacities worrisome for pneumonia, suspect atypical pneumonia with mild mediastinal adenopathy. The abdomen was benign. Human immunodeficiency virus (HIV) testing came back negative; the rheumatoid factor was negative. Legionella urine antigen and mycoplasma titers were sent. Doxycycline and ceftriaxone were discontinued, and the patient was started on Levaquin 750 mg IV daily. 

He began to defervesce. The nausea and vomiting resolved. The abdominal pain resolved. The diarrhea resolved, now is deemed to be secondary to antibiotics rather than an infectious etiology. Given the improvement of the temperature curve and leukocytosis, the patient was transitioned to oral Levaquin with plans to discharge to home. 

The health plan's determination is overturned. The requested health service/treatment of inpatient stay for the above-stated dates is medically necessary for this patient
This patient presented with intractable nausea and vomiting, persistent fevers, and persistent leukocytosis of unclear etiology. Also, he was experiencing diarrhea, which led to further dehydration. The patient was at risk of dehydration. In addition, it was necessary to thoroughly evaluate this patient, given his recent history of travel, to determine the cause of his fevers, to prevent increased morbidity and mortality in this young individual. Without the multidisciplinary approach and prolonged hospitalization, this could not be achieved. 

Throughout the hospitalization, the patient was treated with antiemetic medications, antidiarrheal medications, broad-spectrum antibiotics, which were readjusted multiple times. It is standard of care, to admit this type of patient under an inpatient level of care, for appropriate evaluation and treatment.