Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infectious Disease-Viral Infection. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission for medical necessity. 
The denial was upheld.

This patient is a female with speech delay, who presented to the emergency room (ER) for fever times (x) 7 days, with a temperature (T) maximum at 103. The fever began 1 week prior and initially her temperature was 101.2 and over 3 days gradually increased to 103 and was persistently 103 for the 4 days prior to arrival to the ER.  Her mother gave the patient Tylenol and Ibuprofen every 4 hours for 3 days. The fever was associated with cough and upper respiratory infection (URI) symptoms, post tussive emesis x 1-3 episodes per night for the prior 5 nights. Her mother endorsed decreased by mouth (PO) intake and decreased wet diapers. There were no sick contacts and no recent travel.
In the ER, the patient was febrile to 103.5 taken rectally, blood pressure was 158/99 (irritable at presentation), heart rate was 154 beats per minute (bpm), respiration rate was 20 bpm, and she was 99% on room air. The physical exam documented an ill appearing patient, crying, and fussy with skin warm to touch. Conjunctival redness was noted bilaterally, no discharge, and cervical anterior adenopathy was noted.
The urinalysis (UA) micro showed no bacteria, red blood cell (RBC) or white blood cell (WBC). The coronavirus 2019 (SARS COV2 IGG Ab) was nonreactive and BioFire was negative.
The cytomegalovirus (CMV) IgM was positive, and she was CMV IgG negative, with Epstein-Barr virus (EBV) equivocal. The assessment at admission was dehydration (moderate), Kawasaki versus (vs) Multisystem inflammatory syndrome in children (MIS-c) unlikely. The plan was for intravenous fluids (IVF), monitor ins and outs, trend inflammatory markers, and monitor fever curve.
The patient was admitted to the pediatric floor. Initially, the patient was on IVF because she was not taking good oral intake, which later resolved, and she was taken off IVF. She was deemed clinically improved. She was cleared for discharge and instructed to follow up with infectious disease the following week and follow up with primary medical doctor (PMD) in 2-3 days.
At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of inpatient stay was not medically necessary for this patient.
At the time of admission MIS-c and Kawasaki disease were both unlikely diagnoses and it was apparent that this patient did not meet criteria for either of these. She was soon found to be CMV IgM positive which explained her illness. The treatment for acquired CMV infection in children is supportive care. She was treated with IVF and antipyretics. Her laboratory studies did not indicate that she had a serious bacterial infection requiring IV antibiotics. This patient did have decreased PO intake, but she did not demonstrate a level of dehydration that would warrant an inpatient level of care. She did have dry lips; she was also described as having moist mucous membranes. The patient was hemodynamically stable, did not have signs of hypoxia, tachypnea without fever or altered mental status. She did not have signs of poor perfusion. She did not have any highly skilled or technical care provided during her stay.
Therefore, the patient did not require an inpatient level of care and the inpatient stay was not medically necessary.