Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fevers, Neck Mass.
Treatment: Inpatient Hospital Stay.

The insurer denied the inpatient hospital stay. The determination is overturned.

The patient had no significant past medical history and presented with a left neck mass, leukocytosis and intermittent fevers. Per his mother, he was in his usual state of health until 10 days prior when he developed fevers. The fevers had been intermittent with a maximum temperature of 101.6 degrees Fahrenheit (F). One day after the fevers started, his mother noticed left neck swelling which had progressively worsened. He also had somewhat decreased by mouth (PO) intake over this time period. His mother noted that he felt "lighter" but did not know the exact weight loss. The urine output also somewhat decreased. Overall, the patient has had less energy. They presented to the primary medical doctor (PMD) on day of presentation. The patient had labs drawn and purified protein derivative (PPD) placed. He was prescribed Amoxicillin. He received 2 doses (2 PM and 9 PM). Labs returned with a white blood cell count (WBC) of 40 with bands and neutrophils, so he was referred to the emergency room (ER) for further evaluation.

In the ER, he was noted to be febrile to 100.8 degrees F but was well appearing. On exam, he had a 3 centimeter (cm) mass to the left posterior cervical area that was tender and mobile. There were no skin changes, mild fluctuance. An ultrasound (US) revealed 2.5 cm heterogeneous soft tissue lesion. Ear, nose, and throat (ENT) was consulted. They evaluated the patient and felt no acute surgical intervention was required but recommended admission for intravenous (IV) antibiotics and serial exams. The patient was given a dose of Unasyn, a normal saline (NS) bolus and Tylenol in the ER. The admission physical exam was the same as the ER with no significant changes. The patient was admitted for IV antibiotics and further work up with diagnosis of lymphadenitis versus (vs) malignancy vs multisystem inflammatory syndrome in children (MIS-C). After admission, the patient defervesced. His clinical course and exams were most consistent with left neck lymphadenitis. He was improving appropriately with IV Unasyn. On the day of discharge, his mother reported the area to his neck appeared to be decreased in size and felt softer. His lab results were trended and his C-reactive protein (CRP) was down from 30.43 to 14.67. His white blood cell count (WBC) was down from 28.09 to 18.37. He was sent home with Augmentin for 7 more days and Tylenol as needed (PRN) for pain. He was also instructed to follow up with his primary medical doctor (PMD) upon discharge.

The requested inpatient stay was medically necessary for this patient.

Given his clinical presentation of enlarged cervical lymph nodes with prolonged intermittent fevers and elevated inflammatory markers, admission for IV antibiotics with close monitoring for response would be necessary. Given the location of his disease process, rapid progression may involve airway compromise via surrounding soft tissues of the neck. With such high inflammatory markers and elevated WBC with left shift, an invasive bacterial infection would be of significant concern and IV antibiotics with monitoring would be in the best interest of the patient. The risk of bacteremia and infection with resistant organisms must also be a consideration when patients present with such high white blood cell count with left shift. Disease progression and worsening in a toddler at times can be very subtle, as due to their developmental stage they may not communicate critical changes in their status. Close monitoring and attention to their vital signs would be prudent. For these reasons, an inpatient stay would be medically necessary.