Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Persistent Fever and Cough
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a young male child with past medical history significant only for eczema that was referred to the emergency department (ED) by his pediatrician for evaluation of prolonged high fever and cough. He had five-day history of fevers to 104.9 degrees Fahrenheit and ten-day history of cough. He was seen in another ED two days prior and was sent home, COVID 19 (coronavirus disease 2019) negative. At the second presentation to the ED, vital signs included temperature 37.6 degrees Celsius, heart rate 123, respiratory rate 24, with 98% (percent) saturation on room air. Examination was (according to the ED record) essentially unremarkable. Chest x-ray was obtained that revealed a large consolidation in the superior right lower lobe consistent with pneumonia. The patient's laboratory evaluation was significant for leukocytosis with white blood cell count of 26.2 thousand, and mild metabolic acidosis with carbon dioxide 19.6. Rapid influenza and respiratory syncytial virus tests were negative. 

The patient was admitted for further management. Admission orders included ceftriaxone daily, antipyretic agents, regular diet, cough management with guaifenesin/dextromethorphan, and vital signs per protocol. The patient continued to spike fevers, but the fevers were decreasing in magnitude until he was afebrile. Blood cultures and viral respiratory panel were negative. By the second day, the patient was afebrile for 24 hours and was feeling better. He was deemed stable for discharge to complete a ten-day antibiotic course with high-dose amoxicillin.

The acute inpatient admission was not medically necessary.

Clinically, pneumonia is typically preceded by upper respiratory tract infection symptoms, including cough and runny nose. The type and degree of symptoms of lower respiratory tract infection depend upon the organisms and stage of illness. 

Tachypnea, fever, cough, and chest pain may all be present. Physical examination findings may include decreased breath sounds, crackles, tachypnea, and shortness of breath. Infiltrate on chest x-ray is supportive of the diagnosis and may be accompanied by effusion. There may be laboratory indicators of infection, including leukocytosis and elevated inflammatory markers. Treatment is based on the suspected cause. Hospitalization may be warranted in the very young, patients with concurrent serious chronic medical conditions, moderate to severe respiratory distress, need for supplemental oxygen, dehydration, inadequate response to outpatient therapy, and complications such as empyema, abscess, or sepsis.

This young school-aged male child presented with prolonged high fever with cough, a large infiltrate on x-ray, and leukocytosis on lab study. He was diagnosed with pneumonia and treated with parenteral antibiotics and cough suppressants. While it was reasonable to monitor him in the hospital while initiating treatment, he was overall hemodynamically stable without significant underlying medical problems or metabolic abnormalities, no oxygen requirement, no impending respiratory failure or sepsis. He did not require acute inpatient hospital admission and could have been safely managed at a lower level of care like observation.