Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Muscle Cramps and Muscle Breakdown (rhabdomyolysis). 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is an adolescent male child with unremarkable medical history. He was taken to the ED (emergency department) for evaluation and management of bilateral calf pain. He noticed the pain in the morning when he woke up and got out of bed. He described the pain as cramping, rated 7/10, worse with weight-bearing. He had played basketball the night before, and the parents were concerned that he was dehydrated. He also had intermittent fevers for several days prior, responsive to Tylenol, as well as runny nose. The patient's vital signs included temperature 99, heart rate 91, respiratory rate 16, and blood pressure 110/62. Examination was significant for moist mucous membranes, clear lungs, benign abdomen, intact peripheral pulses, no calf tenderness, and non-focal neurologic exam. Laboratory evaluation was significant for WBC (white blood cell) count 2.3K (thousand) with 43% neutrophils and 42% lymphocytes, platelets 169K, creatine kinase 1213, and pending respiratory viral panel. Electrocardiogram and T-wave inversion in the V2 and V3 leads with no ST-segment changes (read by emergency department physician). The patient was treated with IV (intravenous) fluids. Pediatrics was contacted, and the child was admitted for observation and further management of rhabdomyolysis secondary to acute viral illness. Urinalysis subsequently returned and was negative. The viral panel was positive for influenza A and enterovirus/rhinovirus. Admission orders included hydration at 1.5x maintenance with normal saline, repeat lab studies in the morning, and Tylenol as needed for pain. The patient remained on IV (intravenous) fluids at 1.5x maintenance. Repeat lab studies revealed increased CK (creatine kinase) to 1492, AST (aspartate aminotransferase) 92, ALT (alanine aminotransferase) 35, alkaline phosphatase 224, unremarkable urinalysis. He remained afebrile throughout his hospital stay, with resolution of pain and improved ambulation. He was deemed stable for discharge to follow-up with his pediatrician. 

The requested Inpatient Hospital Admission was not medically necessary. 

Benign acute childhood myositis (BACM) is a benign condition typically associated with viral infection that presents as sudden onset lower extremity pain and refusal to walk. The pain is generally in the lower leg. Significantly elevated creatine kinase levels and myoglobinuria are unusual for this illness, and generally associated with influenza A infection. This is a condition of children, with increased male to female ratio. For the typical presentation, improvement occurs after two to four days without intervention. Laboratory evaluation should only be done in children who refuse to walk at all. Most commonly these children will have elevated creatine kinase, up to twenty times the upper limit of normal. Imaging is not indicated unless other pathology is suspected. 
Given this child's history, physical exam findings, and laboratory data, he most likely was suffering from benign acute childhood myositis secondary to influenza A infection. His creatine kinase level did not exceed 1500, and he had no myoglobinuria. His pain resolved and he was able to ambulate despite a slight increase in CK (creatine kinase). While it was not unreasonable to observe him in the hospital setting while providing parenteral hydration, he was overall hemodynamically stable with no evidence of impending renal failure and no evidence of developing compartment syndrome. He did not require acute inpatient admission, and he could have been safely managed at a lower level of care.