Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System. 
Treatment: Inpatient Hospital. 
The insurer denied: Inpatient stay. 
The denial is: Overturned in whole. 

The patient is a female who presented to the emergency department with fever, cough, and chest pain. She was well until 4 days prior to presentation when she developed a runny nose and a cough. She then developed chest pain as well as a tactile fever. She described the chest pain as being on the upper right side of her chest with tightness that lasted for 1-2 minutes. Her cough was productive of green sputum and she also had 1 episode of post-tussive emesis. She was brought to the emergency department for evaluation.
In the emergency department she was described as ill-appearing and was found to be significantly tachycardic with a heart rate of 122 beats per minute (bpm) and pain of 7 out of 10 in intensity. Her temperature went up to 39.2 Celsius (C) and there was concern for sepsis. Laboratory values were obtained, and she was found to be positive for influenza A infection. She received ketorolac, Tamiflu, and Labetalol as well as 4 liters (L) of a normal saline fluid bolus. An electrocardiogram (EKG) and echocardiogram as well as troponin values were obtained to rule out pericarditis. She continued to be tachycardic and the intensive care team provided consultation. They felt she was appropriate for admission to the hospital floors for heart rate monitoring and treatment of influenza.
She was admitted with continuous pulse oximetry monitoring and was treated with Tamiflu. Following admission, she continued to have tachycardia with heart rates ranging from 130 to 140 bpm. She was evaluated by cardiology who performed an echocardiogram that revealed normal left ventricular size and function. She was continued on Tamiflu and remained intermittently febrile. By the following day she was tolerating oral fluids and was not in respiratory distress. She was felt to be stable for discharge to home with follow-up as an outpatient. A 24-hour metanephrine test was recommended and plasma catecholamines were pending.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned in whole. 

This is a patient who presented with significant tachycardia in the setting of influenza A infection. Her tachycardia persisted despite receiving appropriate and aggressive fluid resuscitation in the emergency department setting. There was concern for sepsis syndrome as well as possible myocarditis or pericarditis, which can be very serious complications of influenza A infection. In fact, she was evaluated by the intensive care team prior to her admission to see if she might require an intensive care bed for monitoring rather than a standard inpatient bed. She required close monitoring in an inpatient setting with specialty consultation and additional treatments as needed.
The decision-making at the time of admission for this patient was consistent with her young age, the presence of significant tachycardia that was out of proportion to her hydration status and fever, and the need for intensive monitoring with additional prompt initiation of therapies as needed for possible sepsis-like syndrome that can quickly lead to serious morbidity.