Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever, Rash and Pain on Swallowing
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is upheld.

The patient is a school aged male child with medical history significant for autism and prior hospitalization for pneumonia. He presented to the ED (emergency department) with one-day history of pain in the inguinal area. The pain had started suddenly, was intermittent and was described as crampy. He also had five-day history of high fevers to 105 treated with 
antipyretics and resolving the night before. He developed rash after the onset of fevers starting on his cheeks spreading to his chest, upper limbs, inguinal region. He subsequently developed strawberry tongue with red throat that made swallowing painful. He had several episodes of vomiting followed by decreased intake and decreased urine output. The patient's vital signs included temperature 97.7, heart rate 99, respiratory rate 26, blood pressure 87/59. Examination was significant for non-ill-appearing, no acute distress, no pharyngeal erythema or exudate, moist mucous membranes, cracked lips especially at the corners, strawberry tongue, single tender enlarged right anterior cervical lymph node, clear lungs, benign abdomen, regular heart rate and rhythm, faint papular rash over the trunk, dried confluent area of rash on the dorsum of the penis, bilateral inguinal lymphadenopathy. Laboratory evaluation was significant for WBC (white blood count) 16.6 K (thousand), platelets 457 K (thousand), AST (aspartate aminotransferase) 49, ALT (alanine aminotransferase) 174, CRP (C-reactive protein) 5.3, alkaline phosphatase 424, and viral testing (including Covid) was negative. He was admitted for management of possible Kawasaki disease. Additional labs were obtained upon admission, including ESR (erythrocyte sedimentation rate) 41.0, 
procalcitonin 0.58. Monospot was negative, EBV (Epstein-Barr virus) and Mycoplasma titers were negative. Urinalysis was significant for concentrated urine with specific gravity 1.032, protein 30, ketones 40, trace leukocyte esterase, and 5 WBC (white blood cells). Admission exam noted the findings from the ED (emergency department) with the addition of scrotal swelling. The differential diagnosis list included toxin-mediated disease (scarlet fever, toxic shock syndrome), EBV (Epstein-Barr virus) infection, Kawasaki disease, and multisystem inflammatory syndrome (MIS-C). Admission orders included regular diet, IV (intravenous) fluids if ongoing poor oral intake, imaging (echocardiogram, scrotal ultrasound), ID (infectious disease) consultation, Hematology consultation, GI (gastroenterology) consultation. Initial Infectious Disease consultant recommendations included ceftriaxone at meningitic dosing, vancomycin at severe infection dosing, clindamycin, and IVIG (intravenous immunoglobulin) (on hold). GI (gastroenterology) consultant recommendations included monitoring liver function and making medication adjustments as necessary. The patient slept well overnight. He had not voided until the morning with some dysuria. His appetite was near baseline, the sandpaper rash had improved, and his throat erythema was better. 
Strep testing returned positive overnight, prompting transition of antibiotic therapy to amoxicillin. The echocardiogram revealed slight dilation of the left main coronary artery that might represent a normal variant, not recommending aspirin or IVIG (intravenous immunoglobulin). The scrotal ultrasound was also performed, resulting hospital day three with preserved bilateral intratesticular blood flow and bilateral inguinal enlarged lymph nodes. He was deemed stable for discharge on day #3 to follow-up with Cardiology and his pediatrician.

The Inpatient Admission was not medically necessary.

This young child presented with fever and signs and symptoms consistent with scarlet fever as well as Kawasaki disease. He was initially treated with high-dose parenteral antibiotics, narrowing to amoxicillin with positive Strep testing. While it was not unreasonable to monitor him in the hospital for improvement versus deterioration, he was overall hemodynamically stable with no evidence of sepsis, severe dehydration, or further complication of Strep infection. He did not require acute inpatient admission and could have been safely managed at lower level of care.