Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever. 
Treatment: Inpatient Admission. 

The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is a male with a known past medical history for being an premature infant with a NICU (neonatal intensive care unit) stay. The patient presented with multiple days of significant decrease in appetite and drinking with a significant decrease in urine output for 24 hours. The patient had a decrease in activity and responsiveness, with a very ill appearance in the emergency room upon arrival. 

The patient was febrile in the emergency room to 102 with an elevated respiratory rate, elevated heart rate, elevated white count greater than 15, elevated inflammatory markers with a prolactin greater than 10. CRP (C-reactive protein) was elevated as well as other inflammatory markers. The patient had edema of orbital areas with loud snoring present. Tympanic membrane's looked well, creating a clinical picture for a concern for periorbital cellulitis, as well as a number of risk factors present for possible sepsis. 

The patient was started on IV (intravenous) antibiotics. The patient required IV (intravenous) fluids, and the patient required close clinical monitoring to assess clinical condition for possible immediate deterioration. The patient received an appropriate work by infectious disease, cardiology as well as imaging required for the differential diagnosis. Once an improved clinical condition was assessed, as well as appropriate labs and radiological findings, the patient was deemed clinically well for discharge. 

Yes, the Inpatient admission is medically necessary. 

As noted, the patient is a female presenting with multiple days of decreased feeding and drinking with a significant decrease in urine output for 24 hours and the temperature of 102. The patient was very ill-appearing in the emergency room and there was a concern for sepsis as all as well as periorbital cellulitis. Due to the clinical appearance of the child, the need for IV (intravenous) fluids, the elevated white count, the elevated prolactin level, and the significant pathology being considered with very extreme outcomes, an inpatient stay was medically necessary for an appropriate evaluation. If the patient was septic, which was possible due to the vitals and clinical exam, or if the patient had periorbital cellulitis, which is also possible considering the lab values and clinical exam, there could have been a terminal result in the clinical state of the patient if care were not to have been quickly and appropriately given. As such, the care and timing of said care and the duration of monitoring and assessment was medically appropriate and necessary. The patient was cared for and discharged in a medically appropriate fashion for the pathology's being assessed and treated. The denial is overturned. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 

Considering the dehydration and ill appearance of the child, which had been developing for several days, as well as the poor clinical state and febrile condition the patient presented to the emergency room in, it would not have been medically safe or appropriate to place this patient on an observation level of care. If periorbital cellulitis or sepsis is being considered in a dehydrated patient that is not easily arousable and is ill-appearing with multiple elevated inflammatory markers, an inpatient level of stay is medically needed.