Appeal type: Medical necessity
Decision: Overturned

Diagnosis: COVID-19. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is a female infant, born prematurely. She was sent to the ED (emergency department) by her primary care physician for treatment with IVIG (intravenous immunoglobulin). She had been diagnosed with COVID-19 and evaluated in the ED (emergency department) for hypothermia. She subsequently developed a sparse rash on her extremities and feet, as well as some swelling of her hands and feet, and was being admitted with a Kawasaki-like exanthem for IVIG (intravenous immunoglobulin). 

The patient had no fevers, and she was eating well. Both parents were COVID-positive. Her vital signs included temperature 100.1, heart rate 154, respiratory rate 24, and blood pressure 96/58. Her examination was significant for no acute distress, active and playful, normal pharynx, regular heart rate and rhythm without murmur, erythematous rash on the back of the trunk measuring 3 x 3 cm (centimeter) non-blanching, no desquamation, erythematous rash involving hands and feet, and non-focal neurologic exam. She was admitted for evaluation of possible Kawasaki disease secondary to COVID-19 infection, with administration of IVIG (intravenous immunoglobulin) overnight and echocardiogram to follow in the morning. Additional admitting orders included routine vital signs, premedication for the IVIG (intravenous immunoglobulin) with Tylenol and Benadryl, and Cardiology consultation in conjunction with the echocardiogram. 

The patient did well overnight, with significant fading of the rash and decrease in extremity edema. The echocardiogram was performed and was normal, including coronary arteries. Infectious Disease was consulted. The patient was cleared for discharge upon completion of IVIG (intravenous immunoglobulin) with normal echocardiogram, to follow-up in the outpatient setting. 

Yes, the Inpatient admission was medically necessary. 

There have been cases of children infected with COVID-19 that have developed Kawasaki-like symptoms reported in the literature. Kawasaki is a form of vasculitis-inflammation in the blood vessel walls, particularly the coronary arteries, where it can result in aneurysm formation. Regardless of the relationship between COVID-19 infection and development of Kawasaki-like vasculitis, treatment remains the same. In this particular case, the infant had known COVID-19 infection, had been in the ED (emergency department) previously for concerns about hypothermia, and returned with vasculitis-like symptoms including rash and distal edema. Infectious Diseases was consulted with recommendations to treat as if she had Kawasaki disease, with administration of IVIG (intravenous immunoglobulin) and echocardiogram to evaluate for coronary artery pathology. She did well and was discharged upon completion of the infusion. However, despite the short length of stay, management of the novel and potentially critical nature of her presenting symptoms in conjunction with her history of prematurity and young age was most consistent with acute inpatient management. She could not have been safely managed at a lower level of care.