Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fevers, constipation, vomiting, and prolonged breakthrough seizure.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male infant with complex medical history significant for premature birth at 35 weeks' gestation, infant of polysubstance using mother, and seizure disorder diagnosed at two weeks of age with family history of KCNQ3(Potassium Voltage-Gated Channel Subfamily Q Member 3) mutation that presented to the emergency department with two-day history of fevers to 102.9, constipation, and multiple episodes of vomiting. He was irritable and less active than baseline, with decreased intake and decreased wet diapers. About six hours prior to presentation he had prolonged generalized tonic-clonic seizure activity lasting about thirty minutes aborted by clonazepam. Of note, he had received vaccines five days prior and had been hospitalized ten days prior with vomiting and bloody diarrhea. 

The patient's vital signs included temperature 37.2, heart rate 122, and respiratory rate 40. Physical examination was significant for irritability, flat anterior fontanelle, moist mucous membranes, regular heart rate and rhythm, distended abdomen with present bowel sounds, and non-focal neurologic exam. Laboratory evaluation revealed mild hyponatremia (sodium 134), elevated liver enzymes (aspartate aminotransferase [AST] 131, alanine aminotransferase [ALT] 102), elevated alkaline phosphatase (271), urinalysis with large blood and 30 protein, negative Covid, mildly decreased white blood cell (WBC) count (5.1 thousand) with lymphocytosis, and unremarkable C-reactive protein (CRP). Lumbar puncture was attempted unsuccessfully three times; urine and blood cultures were sent. 

The patient was treated with parenteral Keppra and ceftriaxone prior to admitting to the pediatric ward for further management. Admission orders included continuous cardiopulmonary monitoring, regular diet for age, continued ceftriaxone and Keppra, Ativan as needed for seizure, and follow-up on cultures. He did well overnight with no further seizures, cultures remained negative, he passed stool, and he was able to tolerate his diet. The fevers were ultimately considered likely secondary to recent vaccines. He was deemed stable for discharge home to follow-up with Neurology and his primary care practitioner.

No, acute inpatient admission was not medically necessary. 

The patient could have been safely managed in the hospital at a lower level of care such as observation.
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 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 may be the better choice, but 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 (39C). 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. 

This young male infant with seizure disorder at the time of admission, presented with fevers, constipation, vomiting, and prolonged breakthrough seizure. He had been recently hospitalized for vomiting and fevers and had received vaccines several days prior. He underwent partial septic work-up in the emergency department (multiple attempts at lumbar puncture were unsuccessful, ultimately deemed unnecessary to management) with reassuring labs, and was admitted for parenteral antibiotics pending culture results and clinical status. He did well with resolution of fevers, no further seizures or vomiting, negative pending cultures, and able to pass stool. While it was reasonable and appropriate to monitor this relatively complex infant in the hospital with relatively low-risk criteria for sepsis, he was overall hemodynamically stable with reassuring lab studies and no clinical evidence of sepsis. He did not require acute inpatient admission and could have been safely managed at lower level of care such as observation.