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 fully vaccinated male child. He has medical history significant for craniosynostosis status post sagittal cranial surgery. He presented with three-day history of fever responsive to antipyretics. He was drinking well, but his appetite was decreased, and the day prior to admission, he was not making his usual number of wet diapers. He had no cold symptoms, no gastrointestinal symptoms, and no rashes.

The patient was directly admitted to the pediatric floor for evaluation of fevers with concern for possible Kawasaki disease. Outpatient labs had revealed elevated inflammatory markers. Vital signs included temperature 37.5, heart rate 158, respiratory rate 20, and blood pressure 98/57. Examination was significant for non-toxic appearance, no acute distress, posterior pharyngeal erythema with tonsillar exudate and tonsillar hypertrophy, no oral lesions, shotty cervical lymph nodes, red lips, clear lungs, benign abdomen, left foot pes planus, and non-focal neurologic exam. Expanded respiratory pathogen panel was negative. Admission orders included antipyretics as needed, laboratory evaluation (CBC [complete blood count], CMP [comprehensive metabolic panel], CRP [C-reactive protein], ESR [erythrocyte sedimentation rate], blood culture), lead level per parent request due to concerns for environmental exposure, throat culture, urinalysis and urine culture, and regular diet for age.

The patient's laboratory evaluation was significant for WBC (white blood cell) count 10.3K (thousand), platelets 190K (thousand), ESR (erythrocyte sedimentation rate) 78.0, CRP (C-reactive protein) 7.64, AST (aspartate aminotransferase) 59, and negative urinalysis. Echocardiogram was obtained and was negative, as was chest x-ray, electrocardiogram, and abdominal ultrasound. Ophthalmology was consulted with no evidence of inflammation. Infectious Disease was obtained per mother's request because of on-and-off fevers for weeks.

Kawasaki disease was considered unlikely, but additional infectious disease work-up was obtained with Lyme serology, Borelia miyamutoi serology, familial Mediterranean fever serology, ANA (antinuclear antibody), anti-DNA (deoxyribose nucleic acid), CCP (cyclic citrullinated peptide), EBV (Epstein Barr virus) DNA (deoxyribose nucleic acid) PCR (polymerase chain reaction), urine CMV (cytomegalovirus) testing, rickettsial serology, and consideration for genetic testing for periodic fever, including the TAC1 (Tachykinin Precursor 1) mutation.

By day three, the patient was afebrile, with improved intake of fluids and meals. He was deemed stable for discharge home, to follow-up with his pediatrician the following day. No clear etiology of his fevers had been identified, but a comprehensive work-up had been initiated.

Yes, the Inpatient admission was medically necessary.
Acute inpatient admission was medically necessary and appropriate in this case.

With the introduction of various vaccines, the epidemiology of acute febrile illness in infants and young children up to 36 months of age has changed. There has been a dramatic decrease in serious infections due to Streptococcus pneumoniae and Haemophilus influenza type b. Urinary tract infections are now the most common bacterial infection in young infants under three months of age, and pneumonia is most likely in infants and children three to 36 months. Fever is considered to be clinically significant if at least 100.4F (Fahrenheit) or 38 C (Celsius) taken rectally. The other means of checking temperature are considered to be unreliable. History of fever is as clinically significant as fever at the time of evaluation, particularly in neonates. While guidelines historically stratified children into three groups (neonates less than 30 days old, young infants up to 90 days old, and older infants and toddlers up to 36 months old), with the advent of the latest vaccines, the boundaries are blurring.

The most important means of determining if a fever represents a serious infection is the physical exam. There are a number of "red flags" that increase suspicion of serious bacterial infection, including inconsolability, cyanosis, poor peripheral circulation, tachypnea, petechial rash, and seizures. Selected use of laboratory testing and imaging may be necessary to identify serious bacterial infection. Urinalysis is particularly important because of the commonality of urinary tract infection. Although complete blood count is not always useful or predictive, current guidelines recommend obtaining CBC (complete blood count) and blood culture in febrile infants less than three months of age. Both C reactive protein and procalcitonin have been and continue to be explored as useful markers of serious bacterial infection. Currently, procalcitonin is evidenced to be to be the better choice, but expense and delay in obtaining results make it less practical. Chest x-ray is useful in young infants with respiratory symptoms and those with high fevers over 102.2F (Fahrenheit) (39C [Celsius]).

With the current vaccine schedule, meningitis is less common, but lumbar puncture is still indicated in infants one to three months of age with high risk findings such as ill appearance. Rapid viral testing may be useful during epidemics to prevent need for other testing. For infants/children one to 36 months that show signs of serious illness (as listed above), inpatient management is indicated. For well-appearing infants/children one to 36 months of age, urinalysis and urine culture is universally recommended. Even with clear-cut recommendations, there are regional and individual physician preferences that alter patient management. In general, ill appearing patients or those with high fevers should be monitored more closely, typically in hospital.

In this case, this young child presented with acute on chronic fevers, with longstanding history of chronic intermittent fevers and three-day history persistent fevers. He was admitted for comprehensive evaluation of fever without source, with particular concern for Kawasaki disease or periodic fever syndrome. Multiple consultations were sought and numerous diagnostic tests performed in an effort to determine the etiology of his acute on chronic fevers. Although initially significantly elevated, his inflammatory markers improved without antibiotic treatment and his fevers subsided, with improvement in both activity and appetite. No source of fevers was determined, but at the time of discharge multiple test results were still outstanding. Although he was overall hemodynamically stable, he was lethargic and pale with the fevers. The level of care that he received in conjunction with his clinical presentation was most consistent with acute inpatient management. Lower level of care would not have been appropriate in this case.

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