Appeal type: Medical necessity
Decision: Upheld

Respiratory System
Inpatient Hospital

The patient presented with recurrent nightly fevers for 13 days and decreased by mouth (PO) intake for 3 days. His mother reported fevers up to 102 degrees Fahrenheit. He has also had associated nasal congestion, a runny nose and a cough for the past 4 days; denied vomiting, diarrhea or rash. He was recently seen in the emergency room (ER) 3 days prior where he tested positive for rhinovirus/enterovirus. Blood and urine cultures were negative from that visit and lab results were normal so he was sent home with diagnosis of viral illness. The mother was instructed to follow-up (f/u) with infectious disease (ID) if the fever persisted but he was unable to do so because of his insurance. His mother also reported the decreased PO intake for the past 3 days was her major concern. She brought him in to the ER again on the day of admission for PO refusal. The mother reported 3-4 wet diapers (WD) in the previous 24 hours. In the ER a chest x-ray (CXR), abdominal ultrasound (Abd US), complete blood count (CBC), comprehensive metabolic panel (CMP) were normal. Blood culture, Parvo polymerase chain reaction (PCR) and immunoglobulin (Ig)G/IgM, cytomegalovirus (CMV) PCR, Epstein-Barr virus (EBV), Bartonella IgG/IgM were sent and pending. He was started on 1MIVF and remained on fluids as he refused PO. He was Afebrile while in the ED. The patient was then admitted for PO refusal. He had decreased PO intake associated with his illness and only took 2 oz of fluid while in the ER. When attempted to wean off of intravenous fluids (IVF), he refused to drink. He was described as well appearing and afebrile. He was admitted for monitoring of his intake and outputs (Is and Os) as well as a fever. He arrived to the floor in stable condition. Vital signs were within normal limits (WNL). The admission physical exam described the patient as playful and interactive with a music therapist and eating carrots and crackers. Per the physical exam and laboratory studies, he did not meet criteria for typical or atypical Kawasaki disease. He lost his IV around 7:00 PM on the evening of admission and was given a PO trial after that. He had good wet diapers afterwards (about 7 in 24 hours) and took about 20 oz of formula during his stay. He was afebrile since arrival to ER the day prior. At the time of discharge, he had been afebrile for 24 hours. He was taking PO ad lib. He was discharged with no medications and advised to follow up with his pediatrician in 48 hours.
The health plans determination is upheld. He presented with a prolonged fever and decreased PO intake. He had been seen in the ER 3 days prior and noted to be rhinovirus/enterovirus positive. He was admitted for PO refusal. Although there is report of PO refusal, this patient did not have any signs or symptoms of clinically significant dehydration that would require inpatient level of care. His physical exam was unremarkable, his laboratory and radiological studies were also unremarkable. His vital signs were stable and although urine output was decreased it was never described as inadequate. Less than 24 hours after presentation this patient was described as playful and interactive with music therapist and eating carrots and crackers. This patient could have received IVF in the ER with transition to outpatient care with close follow up.  The patient did not meet any criteria for an inpatient level of care. For these reasons, inpatient stay was not medically necessary for this patient.