Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever and cough (flu)
Issue under review: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

No, the Inpatient admission was not medically necessary.

The patient is a female infant. She presented to the ED with same day history of fever to 103-104, loose stool, cough, and decreased oral intake. She had been seen by the pediatrician earlier in the day with recommendations to use Tylenol and saline drops. 

The patient's vital signs included temperature 38.5-39.9, heart rate 179-200, respiratory rate 42-44, and 100% saturation in room air. Examination was significant for being active with strong cry, moist mucous membranes, tachycardia, tachypnea, no wheezing or respiratory distress, benign abdomen, hypopigmented patches over the trunk, and non-focal neurologic exam. Laboratory testing included positive influenza A. Chest x-ray with no focal infiltrates, consistent with viral process or reactive airways inflammation. 

The patient was monitored in the ED for over five hours, during which time she remained tachycardic. The mother declined intravenous (IV) access for IV fluid administration. The patient was admitted for management of persistent tachycardia, tachypnea, and fever. Admission orders included oseltamivir, diet for age with formula as tolerated, nebulized saline ever three hours, nasal drops with suctioning as needed, and anti-pyretics for fever. She continued to spike high fevers, responsive to acetaminophen. 

The patient's oral intake gradually improved to baseline by the day of discharge. She was discharged home to complete a course of oseltamivir and follow-up with the pediatrician in two to three days.

Influenza viral infection is a common viral respiratory illness caused by strains of influenza A or B with a broad clinical presentation for which immunization is recommended annually. Onset is typically acute, and associated with systemic symptoms such as fever, malaise, headache, myalgia, and decreased appetite. Sore throat and cough may be present from the beginning or may develop over the course of the illness. Gastrointestinal complaints may also be present, including nausea, vomiting, diarrhea, and abdominal pain. The most common complications include otitis media and pneumonia. Pneumonia may be viral or the result of secondary bacterial infection with Staphylococcus aureus. Less common complications include myocarditis, encephalitis, myelitis, and Guillain Barre syndrome. Reye syndrome may occur with concomitant administration of aspirin-containing compounds. 

Antiviral agents are available, and if administered early in the course of illness (within 48 hours), decreased duration of symptoms and likelihood of complications. Additional treatment is supportive or related to concomitant complications or bacterial infection. Annual administration of influenza vaccine for prevention is encouraged.

This young female infant presented to the pediatrician's office with cough and high fever. She was referred to the ED for testing and management. She was febrile, tachycardic, and tachypneic. Testing revealed influenza A infection. The family refused IV access, so no IV fluid bolus could be given to counter her decreased oral intake. She remained febrile, tachycardic and tachypneic in the ED over more than five hours of observation. She was admitted for further monitoring. She did well despite persistent fevers. Her appetite returned and she was able to tolerate enough to sustain herself. It was important to continue monitoring for oral intake, signs of dehydration, and signs of impending respiratory failure. However, she was overall hemodynamically stable, with no oxygen requirement, good perfusion and responsiveness, no evidence of significant dehydration, and no signs of impending respiratory failure. She did not require acute inpatient admission. She could have been safely managed at lower level of care, such as observation.