Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diarrhea, Fever & Vomiting.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a female infant. She developed fever and diarrhea. The illness started with an episode of diarrhea for which she was taken to the pediatrician and discharged without concerns. She later developed fever to 101, with no change in appetite or activity. She was taken back to the ED (emergency department) and was found to have oral lesions. The fever persisted with decreased breastfeeding and increased sleepiness. Although both parents were considered to be essential workers, neither had symptoms consistent with COVID-19 (Coronavirus Disease 2019) infection. With the persistent fevers and sleepiness, the pediatrician referred her to the ED (emergency department). 

The patient was evaluated in the local ED (emergency department), where she was found to be febrile to 103.7, tired, not breastfeeding and refusing Pedialyte and formula. Laboratory evaluation revealed metabolic acidosis with CO2 (carbon dioxide) 19 and elevated CRP (C-reactive protein) 15.7. Chest x-ray was reportedly unremarkable. The decision was made to transfer to higher level of care because of concerns for sepsis or COVID (Coronavirus Disease) multi-system inflammatory syndrome. She was treated with Tylenol prior to transfer and had an episode of emesis in route. 

The patient's vital signs upon arrival included temperature 100.7, heart rate 150, and respiratory rate 36. Repeat labs were obtained, with CRP 12.0, D-dimer 2.97, and procalcitonin 1.12. COVID (Coronavirus Disease) testing was negative, as was an expanded viral respiratory panel. The patient continued to refuse to eat, so was admitted for hydration and supportive care for presumed viral infection. 

The patient's admission orders included Pedialyte and breastfeeding ad lib, continuous pulse oximetry, maintenance IV (intravenous) fluids, antipyretics, and neuro checks every four hours. She began to start breastfeeding and drinking was deemed stable for discharge home.

Yes, the Inpatient admission was medically necessary.

With the introduction of various vaccines, the epidemiology of acute febrile illness in infants and young children up to 36 months of age has changed. There has been a dramatic decrease in serious infections due to Streptococcus pneumoniae and Haemophilus influenza type b. Urinary tract infections are now the most common bacterial infection in young infants under three months of age, and pneumonia is most likely in infants and children three to 36 months. Fever is considered to be clinically significant if at least 100.4F (Fahrenheit) or 38 C (Celsius) taken rectally. The other means of checking temperature are considered to be unreliable. History of fever is as clinically significant as fever at the time of evaluation, particularly in neonates. 

While guidelines historically stratified children into three groups (neonates less than 30 days old, young infants up to 90 days old, and older infants and toddlers up to 36 months old), with the advent of the latest vaccines, the boundaries are blurring. The most important means of determining if a fever represents a serious infection is the physical exam. There are a number of "red flags" that increase suspicion of serious bacterial infection, including inconsolability, cyanosis, poor peripheral circulation, tachypnea, petechial rash, and seizures. Selected use of laboratory testing and imaging may be necessary to identify serious bacterial infection. Urinalysis is particularly important because of the commonality of urinary tract infection. Although complete blood count (CBC) is not always useful or predictive, current guidelines recommend obtaining CBC (complete blood count) and blood culture in febrile infants less than three months of age. 

Both C-reactive protein (CRP) and procalcitonin have been and continue to be explored as useful markers of serious bacterial infection. Currently, procalcitonin appears to be the better choice, but expense and delay in obtaining results make it less practical. Chest x-ray is useful in young infants with respiratory symptoms and those with high fevers over 102.2F (39C). With the current vaccine schedule, meningitis is less common, but lumbar puncture is still indicated in infants one to three months of age with high risk findings such as ill appearance. Rapid viral testing may be useful during epidemics to prevent need for other testing. For infants/children one to 36 months that show signs of serious illness (as listed above), inpatient management is indicated. 

This female infant developed progressively higher fevers and refusal to feed, with signs of dehydration and systemic infection on laboratory evaluation (low CO2 [carbon dioxide], elevated CRP [C-reactive protein] and procalcitonin). She had been seen several times by the pediatrician and finally with reports of feeding refusal and lethargy was referred to the ED (emergency department). She was febrile to 103.7 in the first ED (emergency department). They obtained laboratory studies that were indicative of infection without obvious source. She was hydrated and treated with antipyretics and transferred for higher level of care because of concerns for sepsis and COVID (coronavirus disease) MSIS (multi-system inflammatory syndrome). Repeat labs continued to indicate systemic infection, with elevated procalcitonin and CRP (C-reactive protein). She continued to refuse to nurse or drink any fluids. At this point she had failed outpatient management, as well as a reasonable period of observation. Acute inpatient admission was indicated because of her age, the potential for serious systemic infection, and feeding refusal, consistent with the current standard of care as well as general guidelines. She could not have been safely managed at a lower level of care.