Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Infectious Disease.
Treatment:  Inpatient Hospital.

The insurer denied the Inpatient Stay.  The denial is upheld in whole.

The patient is an otherwise healthy male who presented to the emergency department for the complaint of "intermittent nausea, diarrhea, abdominal pains and headaches for two weeks".  He reported recent travel to Guinea, West Africa.  During his travel he was compliant only with three of his four weekly malaria prophylaxis treatments.  He presented to the emergency department (ED) reporting intermittent episodes of fever, chills, headache, and fatigue.  On the day of presentation, he also reported diarrhea, nausea and left upper abdominal pain.

In the emergency department, his vitals were as follows: temperature 37.9, heart rate 100, blood pressure 124/53, respiratory rate 20, oxygen saturation 98%, weight 71.1 kilograms (kg).  His exam by the emergency department (ED) attending described him as "ill appearing" with "mild tenderness to palpation over abdomen."  He received a 2 liters (L) normal saline intravenous bolus and oral Motrin.  He had the following studies: C-reactive protein (CRP) 54 (normal 0-5), Chemistry (sodium 135, potassium 3.3, chloride 101, bicarbonate 26, blood urea nitrogen [BUN] 12, creatinine 0.99, glucose 99, calcium 9.1, aspartate aminotransferase [AST] 20, alanine aminotransferase [ALT] 13, albumin 3.5, bilirubin 1.4), blood culture, complete blood count (CBC) (white blood cell count 6.6, hemoglobin 14.3, hematocrit 4.37, platelets 70 with 7.7% L, 83.2%n, 8.2%m, 0.6%e ), reticulocyte count 0.6 and a blood smear showing Plasmodium (P.) Falciparum with a parasitemia level of 3%.  During the ED course, he was reported to "remain ill appearing" with "periods of tachycardia which suggest a higher potential for instability".  An Infectious Disease consult was obtained and reported "Plasmodium falciparum can cause severe malaria and high parasitemia greater than (>)5%, signs of central nervous system (CNS) hypoglycemia, acidemia".  The decision was made to "admit for the management of malaria and monitor for progression to severe malaria", contact Centers for Disease Control and Prevention (CDC) hotline, perform daily peripheral smears, and start oral Malarone daily for the next 3 days.  The first dose of Malarone was given.

Overnight the patient reported severe headache with photophobia and fever.  He required oral oxycodone x three doses and intravenous morphine and an intravenous normal saline bolus for pain control.  He continued to report headache, fatigue, malaise and had poor oral intake during the day.  His stools were noted to be more solid, and his abdominal pain decreased.  The inpatient team reported monitoring the patient closely, given possible concern for "progression to cerebral malaria".  His repeat labs showed CBC (white blood cell count 3.3, hemoglobin 12.5, platelet 81), Chemistry (BUN 7, Cr 0.93, bicarbonate 21.8, bilirubin 0.7) and a peripheral smear with 1.2% parasitemia.  At 12:38pm, his labs showed CBC (WBC 3, hemoglobin 12.5, platelet 93), CRP 53.2, Chemistry (albumin 2.6, AST 19, ALT 18, glucose 94, bicarbonate 25, BUN 6. creatinine 0.9), and a peripheral smear with 0.5% parasitemia.  The patient took his third and last dose of oral Malarone.

The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

The requested health service/treatment of inpatient stay was not medically necessary for this patient.  The degree of monitoring and treatment he required could have been provided at a lower level of care status.

Patients diagnosed with malaria are generally categorized as having either uncomplicated or severe malaria.  Patients diagnosed with uncomplicated malaria can be effectively treated with oral antimalarials such as Malarone.  However, patients who have one or more of the following: altered consciousness/coma, severe anemia such as hemoglobin less than (< )7 g/dL, renal insufficiency, acute respiratory distress syndrome, shock, disseminated intravascular coagulation, acidosis, liver injury and/or parasitemia of greater than or equal to (>=) 5% are considered to have manifestations of severe disease and should be treated aggressively with intravenous antimalarial therapy and often require a high level of care.  Infection with Plasmodium falciparum can progress to severe malaria ( 1-4).

At presentation, the patient was demonstrating no clinical signs of encephalopathy, clinical dehydration, or shock.  His labs in the ED showed no evidence of severe anemia, parasitemia over 5%, disseminated intravascular coagulation (DIC), acidosis, hypoglycemia, or renal/liver failure.  He was appropriately diagnosed with uncomplicated malaria and received treatment with oral antimalarial medications.  It was appropriate for the patient to be admitted for monitoring given his risk for progression to severe malaria.  At a lower level of care status, the patient could also have been monitored safely clinically and with laboratory testing.  As the patient did not progress to severe malaria, he did not require more intensive level of medical care and did not require an inpatient stay.