Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Fever and rash associated with dehydration
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a medical history significant for prematurity born at 32 weeks' gestation hospitalized in the neonatal intensive-care unit (NICU) for four weeks who presented to the emergency department (ED) with a one-day history of fever and spreading rash. He was not drinking well, and his urine output was decreased. Vital signs included a temperature of 38.7 degrees Celsius, heart rate 172, and respiratory rate 22. The examination was significant for non-toxic appearance, dry mucous membranes, pharyngeal petechiae, vesicular lesions on an erythematous base along the posterior soft palate, clear lungs, tachycardia, benign abdomen, maculopapular rash on the palms and soles and spreading to the buttocks and extremities and face, and non-focal neurologic exam. He failed an oral challenge.
Laboratory evaluation was significant for a normal white blood cell count (WBC) count 9.2 thousand (K), hyperkalemia on venous blood gas (potassium 8.6), normal potassium on metabolic panel (4.7), mild metabolic acidosis (carbon dioxide (CO2) 21), and mildly elevated liver enzymes (aspartate aminotransferase (AST) 63). He was treated with Tylenol and a normal saline bolus prior to admission. The admission diagnosis was hand-foot-mouth disease with mild to moderate dehydration. Admission orders included maintenance intravenous (IV) fluids, age-appropriate diet, antipyretics, and follow-up cultures. His appetite and urine output improved over the course of his hospital stay. He developed warmth, mild erythema, and swelling on the dorsum of the left foot and refused to walk. There were no associated skin lesions. He was treated with Tylenol and after several hours he was able to walk on the foot, with decreased swelling and redness noted. He was at baseline for intake, with adequate urine output. There was a vesicular lesion on his palate, and the maculopapular rash was predominantly on his buttocks and proximal lower extremities. Influenza, coronavirus (COVID)19, and respiratory syncytial virus (RSV) screens were all negative. He was deemed stable for discharge to follow-up with his doctor in two to three days.

The requested acute inpatient admission was not medically necessary. Hand foot mouth disease is a viral illness caused by viruses in the enterovirus group, including coxsackievirus A16 and enterovirus 71. It is transmitted by infected secretions and stool and is acquired through close contact with infected people or their secretions. Generally, the diagnosis is based upon the history and clinical presentation. Signs and symptoms include a low-grade fever, malaise, cough, anorexia, abdominal pain, and mouth sores. Ulcerative lesions may occur in the mouth, typically on the hard palate, tongue, and buccal mucosa. The exanthema involves macules and papules that progress through a vesicular stage and then become ulcerations. The palms and soles may be involved. There is no specific treatment, but supportive interventions such as analgesic and antipyretic medications are appropriate. Occasionally, the rash may be pruritic, and can be treated with anti-pruritic medications. Complications include viral meningitis and encephalitis. Hospitalization is indicated for those patients that are unable to maintain adequate hydration or those that develop serious complications (eg neurologic, cardiopulmonary).
This young male child developed a rash and fever consistent with hand foot mouth disease, likely secondary to Coxsackievirus infection acquired at daycare. He was not drinking well at home, with decreased urine output, and he did not tolerate an oral challenge in the emergency department. While it was reasonable to monitor him in the hospital setting for adequate fluid consumption, he was overall hemodynamically stable with no evidence of impending neurologic or cardiopulmonary involvement. He did not require acute inpatient admission and could have been safely managed at a lower level of care.