Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Earache (both ears).
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission. 
The denial is upheld.

The patient is a female child with medical history significant for neutropenia (most recent absolute neutrophil count [ANC] 5703), seasonal allergies, and obstructive sleep apnea that presented to the emergency department with several day history of bilateral ear pain, rhinorrhea, and slight decrease in input with no change in output. She had no fevers and was at baseline level of activity. The mother also had concerns for vaginal itching over the past three years. 
Vital signs included temperature 36.2, heart rate 73, respiratory rate 22, and blood pressure 114/77. Examination was significant for no acute distress, impacted cerumen bilaterally, and non-focal neurologic exam. Following cerumen removal, the patient was found to have bilateral otitis media. Because of the history of neutropenia, laboratory evaluation was undertaken revealing white blood cell (WBC) count of 9.3 thousand (K) with 64.7% neutrophils (absolute neutrophil count [ANC] 6017). She was admitted for treatment of acute otitis media in the setting of historical neutropenia (not currently neutropenic) with parenteral antibiotics. Cefepime was the recommended agent, so she was given a dose before transferring to the pediatric floor. 
Admission orders included regular diet, A&D ointment for the itching, clindamycin every eight hours for vulvovaginitis, Debrox for the cerumen issue, and vital signs per protocol. The patient remained stable in room air, tolerating her diet. She was deemed stable for discharge to complete a five-day course of clindamycin and continue the Debrox for her ears.

The hospital stay was not medically necessary.
Acute otitis media is a common childhood infection. It is managed almost exclusively in the outpatient setting. One of the only exceptions would be in neonates, where it is assumed to be blood-borne as part of bacteremia. Acute otitis media in a child with normal white count and normal differential would be managed in the outpatient setting unless it was diagnosed in conjunction with another condition that required hospitalization.

This young female child had history of neutropenia and long-standing vaginal itching. Lab studies from the emergency department indicated that she was not currently neutropenic, with an absolute neutrophil count (ANC) greater than (>) 6000. According to the literature, a child is at risk for serious bacterial infection if the absolute neutrophil count (ANC) falls below 500. This child was not at risk. Vaginal itching, particularly if it has been going on for years, is not an admitting diagnosis. It would be appropriate to do an examination, check cultures if necessary (vaginal cultures in a six year old child would not be necessary except in the case of abuse), and treat with topical agents. In this case, there was no reported abuse and she was not neutropenic. This medical problem could have been safely and appropriately treated in the outpatient setting. Hospital admission was not medically necessary in this case.

In addition, according to the literature, a child is at risk for serious bacterial infection if the absolute neutrophil count (ANC) falls below 500. This child was not at risk. Vaginal itching, particularly if it has been going on for years, is not an admitting diagnosis.