Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever and possible infection
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a female infant with a medical history significant for sickle cell disease. She presented to the emergency department with a two-day history of fevers. She was feeding well, with no vomiting, diarrhea, cough, or difficulty breathing. She was up to date on vaccinations. She was taking amoxicillin and folic acid daily. She also had a history of liver biopsy because of severe conjugated hyperbilirubinemia at birth, negative for biliary atresia, but revealing neonatal giant cell hepatitis.

The patient's vital signs included temperature 39.8, heart rate 170, respiratory rate 40, with 100% (percent) saturation in room air. Examination was significant for no acute distress, non-toxic appearance, moist mucous membranes, clear oropharynx, clear lungs, benign abdomen, and non-focal neurologic exam. Because of her history of sickle cell disease, she was admitted for fever workup and antibiotics pending culture results. Hematology was consulted from the emergency department, in agreement with the plan for septic workup.

The patient's laboratory evaluation was significant for venous pH (Pulmonary hypertension) 7.39, venous pCO2 (partial pressure of carbon dioxide) 35.6, lactate 3.6, white blood cell count 6.5K (thousand) with 52% neutrophils, hemoglobin 8.3 (baseline), platelets 309K, glucose 87, sodium 135, potassium 4.4, CO2 (carbon dioxide) 20, reticulocyte 8.49%, total bilirubin 1.7 with direct bilirubin 0.45, aspartate aminotransferase (AST) 58, alanine aminotransferase (ALT) 64, alkaline phosphatase 162, C-reactive protein (CRP) 11.2, lactate dehydrogenase 417, and procalcitonin pending. Chest X-ray was unremarkable. She was given a dose of ceftriaxone prior to transfer to the pediatric floor.

The patient's admission orders included continuous cardiopulmonary monitoring, regular pediatric diet, half-maintenance intravenous fluids, ceftriaxone, Tylenol as needed, and follow-up blood culture.

The patient continued to have fevers through day two, treated with antipyretics. Urinalysis and urine culture were negative. She continued to receive ceftriaxone for possible bacteremia through hospital day four. At that time, she had been afebrile since day # (number) 3. With negative cultures and resolution of fever, she was deemed stable for discharge the next day to follow-up with Hematology and continue daily antibiotics.

The inpatient hospital admission was not medically necessary.

The patient could have been safely managed at lower level of care. Fever in patients with sickle cell disease must be taken seriously. These patients are immunocompromised due to abnormal immune function and functional asplenia. Infection with encapsulated bacteria can be particularly dangerous. In fact, infection is the leading cause of death in children with sickle cell disease. While pneumococcal vaccination and penicillin prophylaxis have reduced the risk of mortality, they have not eliminated it, and any history of fever must be taken very seriously. Chronic pain with superimposed acute pain crises is quite debilitating. Vaso-occlusive pain events account for the most emergency room visits and hospitalizations in these patients.

This female infant with sickle cell disease, up to date with vaccines but incompletely vaccinated, presented with fevers and no other symptoms. Because of risk of significant infection with encapsulated bacteria, it was reasonable to provide parenteral antibiotic therapy pending culture results. However, she was overall hemodynamically stable with baseline hemoglobin level, no evidence of impending sepsis, no significant dehydration, and able to tolerate a regular diet for age. She did not require acute inpatient hospital admission and could have been managed safely at lower level of care [e.g. (for example), observation]. Therefore, the inpatient hospital admission was not medically necessary.