Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lyme Disease
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient was brought to the emergency department (ED) with a six-day history of fevers, fatigue, decreased appetite and headaches, and a blanching macular rash for one day. Two weeks prior, he had been in the Catskill mountains, where the family dog got Lyme disease. A tick was found in the home. He had received his second coronavirus (COVID) vaccine a month prior. Three days prior, he saw his primary care physician (PCP), who did a COVID test, which was negative. At triage, his vital signs were normal. He appeared tired, but nontoxic and in no distress on exam. He had pain on upward gaze and on left lateral gaze, and a blanching red rash on the trunk and extremities. The rest of the exam, including the neurological exam, was otherwise normal. Labs were done in the ED and showed a mildly elevated troponin level at 2.17, but otherwise normal; an electrocardiogram (EKG) and echocardiogram were normal.
The patient was admitted for early disseminated Lyme disease based on the historical presentation. Ceftriaxone was administered in the ED after a head computed tomography (CT) scan and lumbar puncture were done, and the patient was admitted to the pediatric floor before the results were available for further management. The exam was similar on admission. The complete blood count (CBC), metabolic panel, lipase, liver panel, thyroid stimulating hormone (TSH), potential hydrogen (pH), coagulation (coags), and urinalysis (UA) were all normal. The respiratory viral panel was negative. The head CT scan was normal. Lyme immunoglobulin (Ig) M was positive with an elevated titer. Treponemal testing was negative. The cerebrospinal fluid (CSF) was bloody, with 82 white blood cells (WBCs) and 90,000 red blood cells (RBCs) . Intravenous (IV) ceftriaxone was continued, and the troponin values trended downward. On exam, his pain with upward and lateral gaze persisted and he also had some neck pain. His eye and neck pain had mostly abated. He remained afebrile and the troponin level had returned to normal, and he was sent home on oral antibiotics. At issue is the medical necessity of an inpatient stay.

The inpatient stay was medically necessary. 
The tentative diagnosis of early disseminated Lyme disease was a reasonable one based upon a history of tick exposure in the Catskills, an endemic area; family dog under treatment for Lyme disease; clinical presentation with a fever, headache, malaise, and fatigue; physical exam with rash and pain with eye movement suggesting possible neurologic involvement; elevated troponin suggesting possible carditis; and a positive Lyme IgM with elevated titer. The patient did not have the classic rash of erythema migrans, but this is not always present in Lyme disease, and his lumbar puncture was bloody and did not show obvious meningitis. Given the reasonable concern for early disseminated Lyme with possible neurologic and cardiac involvement, however, admission for IV antibiotics would be recommended until there was improvement. His eye pain had reduced and his troponin was heading in the right direction, so discharge on oral antibiotics was safe at this point. The hospitalization was medically necessary.