Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cough
Treatment: Full Inpatient Hospital admission
The health plan denied: Full Inpatient Hospital admission
The determination is: Overturned

The patient is a female child with recent and remote history of gastroesophageal reflux disease (GERD) who was referred to the emergency department (ED) for evaluation of a three-day history of congestion with cough productive of yellow phlegm, decreased oral intake, weakness and sleepiness, and two-month history of nausea and acid reflux symptoms. Additional medical history included moderate persistent asthma, two infections with COVID-19, and enuresis treated with biofeedback. 
Evaluation in the ED included lab work, an abdominal ultrasound, a chest x-ray, a thyroid ultrasound, and an electrocardiogram (EKG). Significant results from diagnostic testing in the ED included respiratory viral testing positive for human metapneumovirus, a bedside glucose of 142, a white blood cell (WBC) count of 4.1, a serum glucose of 135, an aspartate aminotransferase (AST) of 34, and an alkaline phosphatase of 187. The abdominal ultrasound was significant for borderline enlarged spleen. The thyroid ultrasound was significant for bilateral hypoechoic nodules. The EKG was interpreted as normal with normal sinus rhythm. 
She was admitted for management of viral syndrome secondary to human metapneumovirus infection associated with poor oral intake and dehydration. Admission orders included regular diet as tolerated, intravenous (IV) fluids at maintenance, Flovent as additional asthma controller medication, gastroenterology (GI) consultation, antipyretics as needed, and consideration of antibiotics if fever spikes. She did well overnight. She voiced that she was hungry but ate only a minimal amount, complaining of "queasiness." She remained afebrile and was not using albuterol. She slept well overnight but was still not eating much, complaining of ongoing nausea. The GI consult was completed with recommendations to check celiac panel labs and switch from Pepcid to Protonix. Nutrition was consulted, as was Endocrinology for evaluation of thyroid nodules. She was given questionnaires to screen for anxiety and depression. Endocrinology recommendations included referral for fine needle aspiration of a left thyroid nodule with a Pediatric Interventional Radiologist. She remained on IV fluids with ondansetron for nausea. She was eating more food items but continued to have nausea upon awakening. The repeat serum glucose was 85. The family was given options for high calorie foods, and she was encouraged to eat high fiber foods to help with constipation and potassium-rich foods to help with mild hypokalemia. She was transitioned to omeprazole twice daily for a six-week course. Celiac screening labs were negative. She was deemed stable for discharge to follow-up with GI, Interventional Radiology for the fine needle aspirate, and Endocrinology.
At issue is the medical necessity of the full hospital admission.
The health plan's determination of medical necessity is overturned in whole.
The full hospital admission was medically necessary.
This female child was initially referred to the ED because of recent onset of productive cough, decreased oral intake, and weakness, but once she presented for evaluation, she reported difficulty swallowing with a feeling of fullness in her throat. This prompted additional work-up to include thyroid labs and ultrasound. She was diagnosed with acute human metapneumovirus infection with dehydration as well as thyroid nodules with normal thyroid function, nutritional concerns with poor weight gain, and ongoing gastroesophageal reflux. All of these issues were addressed during this admission, complete with diagnostic studies, subspecialist consultations, and arrangements for outpatient procedures. The level of care provided was most consistent with acute inpatient level of care, and the entirety of this hospital admission was medically necessary and appropriate.