Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic weight loss; Dehydration.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male teen with remote history of recurrent ear infections that contracted Covid (Coronavirus Disease) infection earlier in the year and subsequently lost fifty pounds unintentionally. He was seen by his primary care practitioner and referred to the ED (emergency department) for admission of chronic weight loss and dehydration. There was concern for occult malignancy or endocrine disorder. He denied fevers and abdominal pain.

The patient's vital signs included temperature 98.6, heart rate 86, respiratory rate 18, and blood pressure 134/86. Examination was significant for no distress, appropriate interactions, no palpable lymphadenopathy, clear lungs, non-tender abdomen, and non-focal neurologic exam. Complete blood count and metabolic panel were unremarkable. Additional history included fatigue, exercise intolerance, labs positive for EBV (Epstein Barr virus) antibodies, hypertension, proteinuria, normal thyroid and diabetes labs, and renal ultrasound revealing splenomegaly.

The patient was admitted following discussion with Oncology for evaluation for malignancy including possible bone marrow aspiration. Following admission, additional lab work included EBV titers, HIV (human immunodeficiency virus) testing, mono screen, blood culture, inflammatory markers. Covid testing was negative. Endocrinology, Gastroenterology, and Psychiatry were consulted.

The patient was able to eat during his hospital stay. The extensive work-up was completed, with the most notable results positive for recent EBV infection. He was given appropriate outpatient referrals and discharged home.

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

Infectious mononucleosis presents with typical signs and symptoms: pharyngitis, fatigue, fever, and cervical lymph node involvement. Other clinical findings include abdominal pain, hepatosplenomegaly, nausea and vomiting, and palatal petechiae. Hepatitis is typically subclinical and occurs in about 75% of cases. The usual cause is EBV infection, although some patients have concurrent streptococcal pharyngitis. Complications include airway obstruction, meningoencephalitis, and splenic rupture, although these occur rarely. Treatment is supportive in nature. Corticosteroids may be prescribed for patients with significant airway inflammation/obstruction or autoimmune complications. Antibiotics are used to treat concurrent streptococcal infections.

This male teen presented to the ED following referral by his primary care practitioner for continued evaluation of fifty pound weight loss. He had already undergone significant outpatient evaluation with lab studies and imaging with no clear etiology for his symptoms and weight loss. There was concern for malignancy as well as other possible underlying conditions. This prompted multiple consultations (Nephrology outpatient, Gastroenterology, Oncology/Hematology, Endocrinology, and Psychiatry) and additional lab work. After numerous laboratory and imaging studies were completed and he demonstrated ability to eat sufficiently without signs or symptoms of refeeding syndrome, he was deemed stable for discharge.

Despite outpatient evaluation, this patient had persistent signs and symptoms without clear underlying etiology, prompting inpatient admission and evaluation for possible malignancy. Acute inpatient admission was medically necessary and appropriate to provide comprehensive and extensive medical diagnostic services; observation level of care would have been inappropriate in this case, insufficient for this patient's needs.