Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Upper respiratory tract infection
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission. 
The denial is overturned.

This patient is a male child with a past medical history notable for short bowel syndrome, TPN dependency, Hirschsprung's disease status post ileostomy, Waardenburg syndrome, anemia, eczema and repeated central line infections with resistant organisms that presented to the Emergency Department for assessment and management of low grade fever (100 F axillary), runny nose and cough then x 2 days. He also vomited but does so normally. His mother was sick with an upper respiratory tract infection. There were no associated chills, travel, distension change in ostomy output, or weight loss. The patient's vitals on arrival were notable for blood pressure 102/80, heart rate 125, temperature 36.9 C, respiratory rate 36 and room air oxygen saturation of 100%. Admitting weight was 9.8 kilograms and height was 71 centimeters. Physical exam showed a well-developed, well-nourished male in no apparent distress.

This child had low grade fever with an indwelling central venous catheter in the setting of upper respiratory infection (URI) symptoms and a sick contact. His history suggests that he has had several severe central line infections, some with resistant organisms. His treating team chose to treat him with empiric antibiotic coverage pending culture results x 48 hours. 

In an overview of complications of central venous catheters and their prevention from UptoDate (attached in pdf format) the authors state the following regarding systemic bacterial infection: "Clinical features and diagnosis - Catheter-related bloodstream infection should be suspected in any patient with a catheter and symptoms or signs of sepsis, infective endocarditis, or septic embolism particularly when there is no clinical evidence for an alternative source of infection. Fever and/or chills are nonspecific but are the most sensitive clinical manifestations of catheter-related bacteremia. Whenever a bloodstream infection is suspected, blood cultures should be drawn. The diagnosis of catheter-related bloodstream infection is based on blood cultures (obtained prior to initiation of antibiotic therapy) of the same organism from at least two blood samples, one from the catheter and one from a peripheral site. 

Treatment - Empiric antibiotic therapy is initiated once blood cultures are obtained and tailored to their results. The duration of treatment is based on the severity of clinical manifestation, infecting organism and whether the catheter has been removed."

Although this patient presented with low grade fever, a sick contact and symptoms of an upper respiratory tract infection it is imperative to send blood cultures and deliver empiric antibiotics with coverage depending on the sensitivities of recent prior infection as was done in this case. The fact that he had no obvious signs of sepsis is insufficient to exclude a catheter infection. The treating team acted in accordance with current standard medical practice. This admission was medically necessary and medically prudent to address such a patient with fever and an indwelling central venous catheter in accordance with the published literature. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital admission is substantiated.  The insurer's denial is overturned.