Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Fever and Vomiting.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a previously healthy male.  He presented to the ED (emergency department) after having returned from summer camp with four-day history of abdominal pain, three-day history of fever to 104.2, and intermittent vomiting.  The abdominal pain was intermittent, epigastric in location, non-radiating, and rated 2/10.  He had four episodes of emesis with no diarrhea.  Remote COVID (coronavirus) testing was reportedly positive.

The patient's vital signs included temperature 99.9, heart rate 120, respiratory rate 18, and blood pressure 114/72.  Physical examination was significant for no apparent distress, normal oropharynx, clear lungs, soft non-distended abdomen with epigastric tenderness, and non-focal neurologic exam.  An electrocardiogram and chest x-ray were obtained.  Chest x-ray was unremarkable, and ECG (electrocardiogram) revealed only sinus tachycardia.  Laboratory evaluation was significant for significant leukopenia with WBC (white blood count) 1.4K (thousand), normal hemoglobin, thrombocytopenia with platelets 92K (thousand), significant bandemia with bands 30%, mildly elevated transaminases (AST [aspartate aminotransferase] 64, ALT [alanine aminotransferase] 53) otherwise unremarkable metabolic panel, elevated LDH (lactic acid dehydrogenase) 282, normal uric acid 7.4, normal ESR (erythrocyte sedimentation rate) 9 with elevated CRP (C-reactive protein) 2.71 and elevated ferritin 373.1, elevated D-dimer 1463, normal procalcitonin 0.4, normal BNP (brain natriuretic peptide) 7, and normal troponin.  COVID (coronavirus disease) testing (SARS [severe acute respiratory syndrome] Covid [coronavirus] IgG [immunoglobulin g]) was negative. 

With the laboratory tests, multiple consultants were contacted Pediatrics (Peds) Hem/Onc [hematology/oncology], Peds Cardiology, Peds ID [infectious diseases]) for recommendations.  The patient was treated with a fluid bolus and ceftriaxone.  With serial exams, he did not meet criteria for activation of the severe sepsis/septic shock protocol.  However, there remained concern for bacteremia, with recommendations to admit for further testing and monitoring.  The working admission diagnosis was viral gastritis.  Admission orders included echocardiogram, follow-up labs (viral titers, blood culture), viral panel, and IV (intravenous) fluids. 

The echocardiogram revealed only mild tricuspid regurgitation, and the viral panel was negative.  The Hem/Onc (hematology/oncology) consultant recommended no further work-up but to follow-up in clinic in a week.  The patient was able to tolerate an advancing diet, with no further abdominal pain or vomiting.  He remained afebrile and was no longer tachycardic.  He was subsequently deemed stable for discharge.

No, the Inpatient Admission was not medically necessary.

This young male presented to the ED (emergency department) upon recommendation of his primary care physician because of several days of fever and abdominal pain.  Upon evaluation, he was found to have lab abnormalities that were concerning for a possible significant underlying illness.  While in the ED (emergency department), multiple consultants were contacted, with recommendations for further evaluation and continued monitoring.  The patient remained hemodynamically stable in the ED (emergency department) with no further emesis or fever.  The additional studies failed to reveal significant underlying pathology. 

While it was not unreasonable to monitor this patient for ability to tolerate fluids, follow the evolution of his tachycardia, and follow-up the results of his myriad lab studies, he was overall stable and did not require acute inpatient admission.  He could have been safely managed at a lower level of care.