Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Herpangina.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient had 5 days of a tactile fever, 3 days of painful blisters in the mouth and decreased by mouth (PO) intake. As per her mother, the patient had a tactile fever since 5 days prior to admission. The mother did not give any medication for the tactile fever. 3 days prior to admission the patient started to develop painful blisters in the mouth for which she went to urgent care and was diagnosed with hand foot mouth disease. They recommended giving her Tylenol for the pain. Her mother was giving Tylenol every 4 hours for the pain, however, the blisters were progressively getting worse and the PO intake was reduced so the mother decided to bring the patient to the emergency room (ER).
As per the mother, the patient did not have any tactile fever on the day of admission. Her mother stated that she had mild congestion on the day prior. The patient started daycare the same week of presentation. Her mother denied a rash, cough, diarrhea, vomiting, sick contact, or contact with a coronovirus disease (COVID) positive patient.
In the ER, the patient presented with aheart rate (HR) of 126, respiratory rate (RR) 24, temperature 98.8 degrees Fahrenheit, and oxygen saturation (O2 sat) 99%. On exam, she was described as not in distress and noted to have vesicles of the lips, tongue and pharynx. She had dry mucous membranes. She was diagnosed with decreased PO intake and dehydration. A basic metabolic panel (BMP) and COVID test was done in the ER. The BMP revealed carbon dioxide (CO2) 15 indicating dehydration and COVID testing was negative. An initial point of care (POC) showed a low glucose of 54 and a repeat 2 hours later trended up to 76. The patient was admitted to the pediatric floor due to decreased oral intake and moderate dehydration caused by painful blisters to her mouth. On admission, she was hemodynamically stable with signs of dehydration. She was placed on intravenous fluids (IVF) and pain control medication for herpangina. During hospital day number (#) 2 she was able to eat well, was well hydrated and tolerating solids. Patient was evaluated by the team and found to be cleared for discharge with instructions to follow up with the primary medical doctor (PMD) after discharge.
At issue is the medical necessity of an inpatient stay.

The requested inpatient stay was medically necessary for this patient. This patient presented with clinically significant dehydration. At the time of presentation patient had dry mucous membranes, metabolic acidosis with a CO2 of 15 as well as hypoglycemia with an initial glucose of 54. Due to the pain she was experiencing from the vesicles in her mouth, she was unable to maintain adequate hydration and would need intravenous fluids (IVF) pending recovery from her illness. The current literature on this topic suggests an indication for hospitalization include the inability to maintain adequate hydration. Also, for patients with clinical evidence of dehydration, admission is also suggested if "substantial difficulties exist in administering oral rehydration therapy (ORT), including intractable vomiting, oral rehydration solution (ORS) refusal, or inadequate ORS intake" or "factors such as young age, unusual irritability or drowsiness, progressive course of symptoms, or uncertainty of diagnosis exist that might indicate a need for close observation". This patient, at the time of presentation would require inpatient level of care based on these criteria. She was seen as an outpatient 3 days prior and failed outpatient management with pain management and attempted oral rehydration. Admission for rehydration and close monitoring would be in the best interest of this patient.