Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Influenza A
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is a toddler female child, born at term. She presented to the ED (emergency department) with fever, cough, fussiness, and runny nose. She had one episode of turning purple during a bottle feeding that lasted two to three minutes. She was treated with Tylenol about seven hours prior to presentation. The patient's vital signs included temperature 104.8, heart rate 166, respiratory rate 30, and 95% oxygen saturation in room air. Examination was significant for non-toxic appearance, moist mucous membranes, clear breath sounds, retractions, and non-focal neurologic exam. Chest x-ray was obtained revealing no acute disease. Viral respiratory panel was positive for influenza A. The patient was treated with Tylenol, dexamethasone, and Tamiflu prior to admission to the pediatric floor. Admission orders included routine vital signs, Tylenol and ibuprofen as needed for fever, continued Tamiflu course, and regular diet for age. She slept well overnight, fed well, and remained afebrile. She had no further purple spells. She was deemed stable for discharge to complete a course of Tamiflu.

The Inpatient Hospital Admission was not medically necessary.

Influenza viral infection is a common viral respiratory illness caused by strains of influenza A or B with a broad clinical presentation for which immunization is recommended annually. Onset is typically acute, and associated with systemic symptoms such as fever, malaise, headache, myalgia, and decreased appetite. Sore throat and cough may be present from the beginning or may develop over the course of the illness. Gastrointestinal complaints may also be present, including nausea, vomiting, diarrhea, and abdominal pain. The most common complications include otitis media and pneumonia. Pneumonia may be viral or the result of secondary bacterial infection with Staphylococcus aureus. Less common complications include myocarditis, encephalitis, myelitis, and 
Guillain Barre syndrome. Reye syndrome may occur with concomitant administration of aspirin-containing compounds. Antiviral agents are available, and if administered early in the course of illness (within 48 hours), decreased duration of symptoms and likelihood of complications. Additional treatment is supportive or related to concomitant complications or bacterial infection. Annual administration of influenza vaccine for prevention is encouraged. 
This young female infant presented to the ED (emergency department) with high fever, cough, and congestion. She had an episode at home during a feeding where she turned purple. It lasted a couple minutes and she recovered spontaneously. She had high fever in the ED (emergency department) but was otherwise well-appearing with a non-focal examination. While it was not unreasonable to monitor her in the hospital for additional spells while treating with Tamiflu, she was overall hemodynamically stable with no significant respiratory distress, no further spells, and no further fevers. She did not require acute inpatient admission and could have been safely managed at a lower level of care.