Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a medical history significant for cerebral palsy, possible muscular enzyme deficiency, feeding difficulties status post gastrostomy tube placement, asthma, history of aspiration pneumonia, and recent ear, nose, and throat (ENT) surgery (tonsillectomy, cord polyp removal, bronchoscopy) and was taken to the emergency department (ED) with a fever to 103 degrees Fahrenheit and refusal to eat. He had one episode of bloody emesis the evening of his surgery. He was treated round-the-clock post-operatively with Tylenol and Motrin for pain. He also had decreased activity. His mother was administering free water via his gastrostomy tube every three hours. Vital signs included temperature 38.1 degrees Celsius, heart rate 123, respiratory rate 22, and blood pressure 119/72.
Examination was significant for no acute distress, mildly dehydrated appearance, dried crusted blood at the base of his nostrils, dry cracked edematous lips, moist oral mucosa, submandibular lymphadenopathy, clear lungs, benign abdomen, and good perfusion. Laboratory evaluation revealed leukocytosis (white blood cell count (WBC) 19.0 thousand (K) with 77.4% neutrophils), negative respiratory pathogen panel, elevated C-reactive protein (CRP) (4.945), ketonuria, and low normal carbon dioxide (CO2) (23). A chest x-ray was unremarkable. He was treated with two intravenous (IV) fluid boluses and admitted for ongoing hydration and pain management in the setting of a recent tonsillectomy.
Admission orders included Tylenol as needed, Unasyn every six hours, ENT consultation to follow-up surgery, infectious disease (ID) consultation to help with sourcing the fever, continued asthma home treatment, Toradol every six hours for pain, soft diet and nectar thickened liquids by mouth with continuous Pedialyte via gastrostomy tube at a maintenance rate. An ENT consultation recommended ongoing fever control, diet as tolerated, intravenous (IV) fluids pending adequate oral intake, pain management with Tylenol and Motrin. Infectious Disease consultation recommended continued antibiotic therapy due to history of recurrent infections. He was initially febrile. The blood culture was negative and a urine culture grew a small amount of normal urogenital flora. Nutrition was consulted to help with free water requirement. Repeat lab studies  revealed improvement in the leukocytosis. His fevers resolved, and he was deemed stable for discharge to complete a course of antibiotics with Augmentin. At issue is the medical necessity of an inpatient stay.
Acute inpatient admission was not medically necessary for this patient. He could have been safely managed at a lower level of care.
Adenotonsillectomy is a common surgical procedure in children and is considered to be painful, particularly in the early post-operative period. Up to a week post-operative, children continue to complain of significant discomfort. Patients frequently seek out medical attention, with the majority of patients returning during the first post-operative week for evaluation of bleeding, pain, and dehydration. This young male child presented with fevers and decreased intake following tonsillectomy and polypectomy. He was mildly dehydrated on exam and treated with two fluid boluses in the ED. He was admitted for pain management and hydration. He was evaluated by ENT with recommendations to continue providing pain management in the setting of post-operative fevers that were not concerning. ID consultation was also sought with recommendations to continue antibiotics due to history of recurrent infections. He did well with resolution of fevers and improved intake.
While it was reasonable to monitor this child in the hospital for resolution of fevers and improvement in intake, he was overall hemodynamically stable without evidence of severe dehydration, electrolyte imbalance, or signs of impending sepsis. He did not require acute inpatient admission and could have been safely managed at a lower level of care.