Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Meningitis 
Treatment: Inpatient Hospital Stay 

The insurer denied the inpatient hospital stay. The determination is upheld. 

This patient with a past medical history of asthma who presented to the hospital with a fever, generalized weakness, and fatigue in addition to a sore throat. She had been prescribed Levaquin in the outpatient setting but her symptoms had persisted. 
On presentation to the hospital, she was febrile to 102.9 degrees Fahrenheit with blood pressure 114/90, heart rate 98, respiratory rate 16, and an oxygen saturation of 100% on room air. The exam otherwise noted her to be in no acute distress, non-toxic appearing, with neck supple. Labs resulted with a white blood cell count (WBC) of 13.8, hemoglobin 15.1, platelets 231, sodium 135, potassium 3.9, blood urea nitrogen (BUN) 9, creatinine 0.9, liver function tests within normal limits, lactic acid normal, and C-reactive protein 1.1. Influenza testing was negative. A urinalysis did not show evidence of an infection. A chest x-ray showed no acute process. She was brought into the hospital with a concern for acute febrile illness with a headache that persisted despite treatment with outpatient Levaquin and with plans for an infectious disease consultation, intravenous (IV) doxycycline, computed tomography (CT) scan of the head, and follow up blood cultures. 

Infectious disease saw the patient with the assessment that she had an unknown acute febrile illness and agreed with the plans noted above. The issue under review is whether care at the inpatient level of care was medically necessary. 

Inpatient stay was not medically necessary. 

The patient continued to have fevers up to 101.5 degrees with mild tachycardia, normotension, and ongoing headache without neurologic deficits or altered mental status. The infectious disease consultation was that she had a viral syndrome versus meningitis with plans to change her from doxycycline to ceftriaxone with a lumbar puncture recommended and consideration of a neurology consult. The lumbar puncture was performed and was demonstrative of increased white blood cells and total protein suggestive of aseptic meningitis. She continued to have a fever up to 101 degrees with vital signs otherwise stable. Infectious disease added fluconazole with the assessment that "aspectic meningitis was likely" and with plans otherwise to pursue magnetic resonance imaging (MRI) of the brain. The MRI showed no obvious abnormalities. She was afebrile for 24 hours with the headache better. No new studies were performed. She was discharged. This patient presented with an ongoing fever and headache without significant leukocytosis and in the setting of having not improved on outpatient Levaquin. Though she stayed in the hospital for 6 days, it is unclear why the inpatient stay was necessary in the absence of abnormal vital signs aside from fever, neurologic deficits, neck stiffness, or altered mental status or why the patient could not be discharged after lumbar puncture for further work-up as an outpatient. Though the diagnosis of aseptic meningitis was made, this diagnosis in itself does not require care at the inpatient level of care in the absence of hemodynamic instability, neurologic deficits, altered mental status, or other acute issue requiring hospital level of care. Inpatient care was not medically necessary. 

In the absence of hemodynamic instability, neurologic deficits, altered mental status, immunocompromised state, or other acute condition requiring hospital care, with it noted that many young patients even with aseptic meningitis can be cared for safely in the outpatient setting.