Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rhino enterovirus, Sepsis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.
	
This patient presented with fever. When due for breast feeding, the patient's mother found the patient warm to touch. The patient's temperature was 100.8 Fahrenheit (F). The patient's mother gave the patient Tylenol, and the patient went back to sleep.  The patient was still warm to touch with a temperature of 100.4 F. The patient's mother gave Tylenol again and the Pediatrician advised the patient's mother to go to the emergency room (ER).  History included family members with "colds." The patient was reported to be tolerating breast milk well. On examination, rectal temperature was 99.3 F (37.3 Celsius (C)). Heart rate and respiratory rate were 168 and 34 per minute, respectively (normal). Oxygen saturation on room air was 100%. On examination, the patient was "active, alert, well-hydrated in no distress. Looks well." Laboratory studies included white blood cell count (WBC) 8.9 (normal), cerebrospinal fluid (CSF) (likely traumatic tap) with color: red, cloudy and WBC 28 with red blood cells (RBC) 34,500 (no organisms seen), a normal basic metabolic panel, normal urinalysis, and a procalcitonin of 0.3 nanograms/milliliter (ng/ML) (normal). As documented, "This patient is here for fever work-up in the setting of likely upper respiratory infection (URI), bacteremia and meningitis also must be ruled out."  In addition, the attending physician documented: "non-toxic appearing but sedate" and that the cardiac examination found "S1 and S2 normal; no murmur, central and peripheral pulses are palpable; mottled." The patient was admitted with concern for sepsis and treatment included empiric intravenous (IV) Ampicillin and IV Ceftaxime. Following admission, the patient remained afebrile. Cultures at 24 hours showed no growth. A respiratory viral panel was positive for rhino enterovirus. The patient was discharged home.

According to Milliman Care Guidelines (MCG): P-410, Sepsis and Other Febrile Illness without Focal Infection, admission is indicated for: Admission is indicated for 1 or more of the following:

	Infant 29 days to 90 days of age with temperature of 100.4 F (38 C) or greater and 
	Signs of poor perfusion (e.g., cyanosis, mottled skin) 
	Parenteral antimicrobial regimen that must be implemented on inpatient basis

Although the infant did test positive for rhino enterovirus, at the time of admission, a bacterial infection remained a possibility. In view of the patient's age (28-29 days), admission for administration of parenteral antibiotics was reasonable and in accord with the standard of care (1).

Thus, with retrospective knowledge of outcome, the insurer has determined that the provider should have anticipated (at the time of admission) a negative sepsis work-up and no subsequent worsening in condition.  Therefore, the patient should have been placed in observation and not admitted as an inpatient.  The provider responded that the patient "was admitted for an infectious process causing sepsis requiring IV antibiotics and close monitoring for deterioration. Concern for neonatal sepsis given fever and relative immunosuppression" (2).  

Herein, the provider's decision to admit was reasonable. There was no obligation to initially pass through an observation period given the patient's presentation and possibility of the patient's condition subsequently worsening.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient is substantiated.