Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever and Rash
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld. 

The patient is a male infant born prematurely that presented to the emergency department with six-day history of fever to 102.8 and one-day history of rash, mouth lesions, and puffy hands and feet. He was seen by his pediatrician during the illness, prescribed anti-pyretics with some benefit. He was not eating but was drinking, albeit with decreased urine output. He also had some diarrhea but no vomiting. The mother was concerned about Kawasaki because another sibling had the illness multiple times. 

The patient was noted to be fussy with decreased energy. Vital signs included temperature 36.6, heart rate 120, respiratory rate 34, and 100% saturation in room air. Examination was significant for congestion and an erythematous reticular rash along with oral lesions. Laboratory evaluation was significant for white blood cell (WBC) count 6.6K with five percent neutrophils, platelets 152 thousand (K), hemolyzed bicarb 13, negative COVID / respiratory syncytial virus (RSV) / flu, lactic acidosis, and relatively unremarkable inflammatory markers. Chest x-ray revealed mild haziness without focal consolidation. He was treated with cefepime, a normal saline bolus, and then maintenance intravenous (IV) fluids, and admitted for further management of acute febrile illness with neutropenia. Admission orders included continued cefepime, follow-up blood cultures, repeat lab studies, and maintenance intravenous fluids. Viral syndrome was the most likely diagnosis. 

The patient's fevers resolved and antibiotics were discontinued with negative cultures. He did not meet criteria for Kawasaki. Over the course of his hospital stay, his absolute neutrophil count increased and began to normalize. His appetite improved. He was deemed stable for discharge to follow-up with Hematology and his primary care practitioner.

No, acute inpatient admission was not 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 or 38C 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 is not always useful or predictive, current guidelines recommend obtaining complete blood count and blood culture in febrile infants less than three months of age. Both C-reactive protein and procalcitonin have been and continue to be explored as useful markers of serious bacterial infection. Currently, procalcitonin may be the better choice, but 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 neonates that present with fever, inpatient management is universally recommended with use of empiric antibiotics pending culture results. Ampicillin and either gentamicin or cefotaxime are the accepted antibiotic choices. For infants/children one to 36 months that show signs of serious illness (as listed above), inpatient management is indicated. For infants one to three months, full septic work-up and empiric antibiotic treatment is appropriate pending culture results. Ceftriaxone is the usual antibiotic choice. For infants older that three months, lumbar puncture is necessary only in the presence of neurologic or meningeal signs. For well-appearing infants/children one to 36 months of age, urinalysis and urine culture is universally recommended. Blood work is only recommended for infants under three months of age and is used to determine necessity of lumbar puncture. An empiric dose of antibiotics may be considered pending culture results. If good and reliable outpatient follow-up is expected, these patients can be monitored outpatient. Inpatient management is reserved for those without reliable outpatient follow-up. Even with such clear-cut recommendations, there are regional and individual physician preferences that alter patient management. In general, ill appearing patients or those with high fevers should be monitored more closely, typically in hospital.

This male infant presented with prolonged fever and new onset rash with concern for Kawasaki. He was dehydrated on exam and responded well to fluids. Laboratory evaluation was significant for neutropenia, not infrequently the result of viral suppression. While it was reasonable and appropriate to monitor this infant in the hospital, he was overall hemodynamically stable with no evidence of impending sepsis, bleeding dyscrasia, or other serious illness. He did not require acute inpatient admission and could have been safely managed at lower level of care.