Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Mouth pain
Issue under review:  Inpatient admission

Determination:  The Inpatient admission was medically necessary.

The patient is a young female child that presented to the ED with four-day history of mouth and dental pain (she had last been seen by a dentist five months prior with no cavities).  Three days prior to presentation, she began to refuse solid food.  Two days prior to presentation she was taken to another ED via EMS for evaluation of malodorous breath, fever, white tongue, green-yellow palate and gums, and inability to swallow Motrin.  She was given an oral numbing rinse and discharged home once the pain had improved.  The patient presented to Brookdale ED the day prior for worsening tooth pain and was diagnosed with gingivitis.  She was given a dose of amoxicillin and discharged home with Motrin and dental follow-up.  Overnight, her condition worsened, with refusal to eat, minimal fluid intake, tactile fever, and increased pain, so she was taken back to the ED.

Vital signs included temperature 37.5, heart rate 105, respiratory rate 22, and blood pressure 120/77.  Examination was significant for lethargy, drooling, diffuse aphthous ulcers, gingivitis, oral thrush, tenderness to palpation, anterior cervical lymphadenopathy, and tenderness to palpation of the anterior neck.  Interventions included x-ray of the neck soft tissues to rule out deep tissue infection, laboratory evaluation, and intravenous (IV) access.  Despite IV fluid bolus and juice, she remained lethargic.  She was unable to tolerate an oral food challenge.  She was further treated with a dose of Decadron and a dose of Motrin.  Laboratory evaluation revealed normal white blood cell (WBC) count, elevated C-reactive protein (CRP) (3.60), and hypoglycemia (glucose 55).  Admission diagnoses included acute herpetic gingivostomatitis and dehydration.  Admission orders included cardiopulmonary monitoring, IV fluids, soft pediatric diet, ibuprofen round the clock, and Magic Mouthwash swish and spit.  Acyclovir was added.  She remained lethargic and unable to tolerate anything orally.  By the date of discharge, her mouth was showing signs of healing.  She was able to tolerate food and fluids, and her pain was well-controlled.  She was deemed stable for discharge home to complete a course of acyclovir.

Primary herpetic gingivostomatitis is a highly contagious common infection in children that usually presents before the age of six years.  The majority of cases are caused by herpes simplex virus type I.  Most children remain asymptomatic.  For those with symptomatic infection, presentation may include erythematous gingiva, mucosal hemorrhages, and clusters of vesicles in the mouth.  Complications may include dehydration and encephalitis.  Supportive care includes pain management and fluids to prevent (further) dehydration.  An oral rinse including antacid, diphenhydramine, and viscous lidocaine may be prescribed.  Acyclovir is the one treatment option and is most beneficial if taken during the first few days of symptoms.

This young school-aged child presented to the ED two times prior to this presentation, offered symptomatic treatment at each presentation, and failing symptomatic treatment each time.  When she presented for the third time, she was moderate-severely dehydrated, lethargic (remaining so after fluid resuscitation and reversal of hypoglycemia), and unable to tolerate her own oral secretions.  She was appropriately admitted to the pediatric service for continued care, remaining lethargic and unable to tolerate anything by mouth until the third hospital day.  By the date of discharge, she had sufficient resolution of symptoms that she was stable for discharge.  With her clinical presentation and multiple failed outpatient visits (each incorporating some degree of observation), acute inpatient admission was the medically necessary and appropriate decision.