Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of asthma and allergic rhinitis who presented to the hospital with complaints of throat pain, odynophagia, fever due to infectious mononucleosis.  The patient was sharing alcoholic beverages with some friends, and the following day she developed a temperature of 105 degrees Fahrenheit.  She was evaluated in the emergency department with a diagnosis of heatstroke, hydrated and slightly improved.  On subsequent days, she continued to feel sick, with difficulty swallowing solid and liquid foods, ongoing pain, and fever.  She was diagnosed with Epstein-Barr virus (EBV) infection by her primary care physician and was noted to have leukocytosis of 12,000.  She was started on Augmentin 500 milligrams (mg) 3 times daily; however, the intervention did not improve her symptoms.  Given the difficulty swallowing, she began to feel weak.  As a result, she came to the emergency department to be evaluated.  On exam, the patient was described as well hydrated, with no acute distress, and non-toxic; with exudates with enlarged bilateral tonsils without a peritonsillar abscess and uvula midline.  A computed tomography (CT) scan of the neck was done in the emergency department, which showed no drainable abscess, no retropharyngeal abscess.  The white blood cell count on admission was 21.9, and lactate was normal.  The chest x-ray did not show infiltrates.  Intravenous (IV) fluids plus dexamethasone were given in the emergency department, and the patient improved enough to be able to tolerate Jell-O and crackers in the ED. 

The patient was admitted to the hospital with ear, nose, and throat (ENT) and infectious disease consultations.  The ENT consultant diagnosed the patient with tonsillitis, most likely due to EBV infection.  They recommended treatment with corticosteroids and advancing her diet as tolerated. 

The infectious disease specialist also evaluated the patient and recommended stopping all antibiotics, agreed with prednisone, and obtaining a throat culture. 

The health plan's determination is upheld. 
The patient had a case of severe mononucleosis, producing severe pain, fevers, leukocytosis, and tonsillar exudates.  This is the typical course of a mononucleosis infection.  The patient showed no signs of severe dehydration or inability to hydrate. This is documented clearly in the admission history and physical, stating that the patient consumed Jell-O and crackers in the emergency department and was able to tolerate these.  The electrolytes and renal function were normal.  This young patient with a robust immune system had a normal lactate level, elevated white blood cell count secondary to splenomegaly, related to EBV infection, and appropriate response.  She was not hemodynamically unstable.  Treatment for this condition is supportive measures.  There was no peritonsillar or tonsillar abscess to require surgical intervention.  The CT scan in the emergency department confirmed this finding.  The patient was treated with oral corticosteroids, which does not require inpatient hospitalization.  There was no demonstrable need for intravenous antibiotics, intensive monitoring of symptoms.  Within 24 hours, the patient was feeling better, described as in no acute distress, and was appropriate for discharge to home with further outpatient care.