Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Fever and sore throat 
Treatment:  Inpatient admission
The inpatient admission was not medically necessary.
The patient is a female child with unremarkable past medical history that presented to the ED with seven-day history of fevers and six-day history or worsening sore throat. She had been seen in Urgent Care and diagnosed with pharyngitis, treated with a course of amoxicillin.  She was then seen in the ED (fever day five), at which time amoxicillin was discontinued because of negative throat culture and rapid strep testing.  She was discharged home, and continued to have sore throat and fevers.  She was refusing to drink and had decreased urine output.  She also complained of headache, neck pain, abdominal pain, runny nose and congestion, and cough.  She had one episode of post-tussive emesis. 

Vital signs in the ED included temperature 38.6, heart rate 149, respiratory rate 30, and blood pressure 114/72.  Examination was significant for no acute distress, anterior cervical adenopathy, moist oral mucosa, bilateral tonsillar hypertrophy with exudates, erythematous posterior pharynx, clear lungs, and benign abdomen.  Laboratory evaluation revealed leukocytosis with white blood cell (WBC) count 12.0K with 34% neutrophils and 14% bands, mildly elevated aspartate aminotransferase (AST) (44), mildly low albumin (3.3), and negative influenza screen.  Neck x-ray revealed an ill-defined rounded density by the posterior aspect of the mandible on lateral projection possible indicative of an overlying structure.  Neck computed tomography (CT) revealed marked bilateral enlargement and edema/phlegmon of the bilateral tonsillar pillars extending into the nasopharynx consistent with acute tonsillitis, with no focal abscess. 

The patient was treated with an intravenous (IV) fluid bolus, ibuprofen, and acetaminophen, and subsequently admitted to the pediatric ward for further management of dehydration.  Admission orders included maintenance IV fluids with three percent correction, regular diet for age, Magic Mouthwash without lidocaine as needed, anti-pyretics, one-time dose of dexamethasone for tonsillar hypertrophy, and follow-up of cultures and imaging studies.  Epstein - Barr virus (EBV) titers were ultimately positive for immunoglobulin G (IgG) and immunoglobulin M (IgM), consistent with acute primary infection.  The patient improved sufficiently during her hospital stay, with no fevers for over 24 hours, good urine output, and ability to tolerate fluids by mouth.  She was deemed stable for discharge.

This female child presented to the ED and Urgent Care multiple times with persistent fevers and sore throat, treated initially with antibiotics.  She eventually refused to drink because of throat pain and became dehydrated (estimated three percent dehydration per the fluids administered).  She was admitted for management of dehydration.  While it was not unreasonable to monitor her in the hospital for resolution of dehydration and ability to drink, she was overall hemodynamically stable, with no evidence of sepsis or severe dehydration.  She did not require acute inpatient admission and could have been safely managed at a lower level of care such as observation.