Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is upheld.

The patient was brought to the emergency department (ED) with two to three days of fever and pain/redness of the left upper gum where he had lost a canine tooth the day before. At triage on 9/26/19, his temperature (T) was 102.9 degrees Fahrenheit, heart rate (HR) 121, respiratory rate (RR) 22, blood pressure (BP) 97/54, and oxygen saturation (O2 sat) 98% on room air. Nursing notes indicated a normal appearance. The physician's note documented a "dry appearing obese child" with "tenderness of the left upper gum" who is "well perfused" with "cap refill intact." The impression and plan of the ED physician was "ten year old male with fever and dental pain with vitals and initial presentation consistent with severe sepsis".
The patient required monitoring and antibiotics. He initially was hypotensive but volume responsive. He was given an intravenous (IV) fluid bolus and IV ceftriaxone in the ED. A urinalysis was normal. The white blood cell count (WBC) was 6.7 with 46% neutrophils and 10% bands. Sodium (Na) was 132, potassium (K) 5.5 (hemolyzed), chloride (Cl) 101, carbon dioxide (CO2) 23, blood urea nitrogen (BUN) 9, creatinine (Cr) 0.5. Venous potential of hydrogen (pH) was 7.41. Another set of electrolytes shortly thereafter showed a Na of 135 and K of 3.8. He was examined by the dentist who thought the "fever not likely due to a dental problem as no signs of infection or swelling noted." He was admitted to the pediatric service. The admission history and physical (H&P) documented normal vital signs, a normal appearing child appearing well hydrated and well-nourished resting comfortably with gingivitis. The plan for the assessment of "dehydration" noted the normal saline (NS) bolus given in the ED and documented "patient responsive and doing well, tolerating po and never had decreased urine output and decreased po." The plan for the assessment for "gingivitis" reiterates the dentist's advice to brush his teeth twice a day and see a dentist twice a year. The plan for the assessment of "fever" is "vitals reviewed from ED and inpatient and patient was not hypotensive for age. Fever likely due to viral infection and not dental." Antibiotics were not continued and he was discharged home. At issue is the medical necessity of an inpatient stay.
The admission was not medically necessary. The admitting physician correctly points out that the blood pressure that concerned the ED physician for "sepsis" was a normal blood pressure for the patient's age and that there was no indication for antibiotics, much less intravenous (IV) antibiotics. The consulting dentist said the gums and teeth were not the source of the fever. Fever alone in an otherwise well patient is not an indication for antibiotics or hospitalization for "monitoring." He did not meet Milliman Care Guidelines for Sepsis and Other Febrile Illnesses Without Focal Infection, Pediatrics. To whatever extent the patient was "dry" as the ED physician noted, the patient was fully fluid repleted with the saline bolus in the ED. He had normal perfusion at all times, was taking by mouth (PO), and had a normal bicarb, potential of hydrogen (pH), and blood urea nitrogen (BUN). All of these findings, plus a urine specific gravity of 1.010 in the ED, suggest he was not dehydrated.