Respiratory System - Cough
Inpatient Hospital

The patient is a female who presented to the emergency department (ED) with a 7 day history of cough, congestion, and fever. Fevers have been reported daily for the past week, ranging from 101-102 Fahrenheit (F), and responsive to Tylenol. Additional symptoms included cough, eye redness, and sore throat. There was no vomiting, diarrhea, rash, ill contacts, or recent travel.

Vital signs in the ED were temperature (T) 39.5 Celsius (C), heart rate (HR) 154, respiratory rate (RR) 24, and oxygen (O2) saturation 97% on room air. Physical exam noted no rashes, bilateral cervical lymphadenopathy, posterior pharyngeal erythema, and mild conjunctivitis.

Labs were remarkable for white blood cell (WBC) count 22.4 with 58% segs and 30% lymphs, hematocrit (Hct) 34, platelets (Plt) 354, and C-reactive protein (CRP) 66.1. Chest x-ray showed bilateral peribronchial thickening with patchy opacities in the lower lung zones with peribronchial thickening. There was suspicion for developing bronchopneumonia, per radiologist reading. Electrocardiogram (EKG) was performed and was normal, and Strep testing was negative. Urinalysis showed large protein and ketones.

Due to the duration of fever and presenting physical exam findings, the patient was admitted for concern of Kawasaki disease versus viral etiology. On the inpatient unit the patient was started on intravenous fluids (IVF), ceftriaxone, and Decadron. Additional lab work came back positive for Epstein-Barr virus (EBV) (immunoglobulin M [IgM] greater than [>]160) as the probable source for fevers and additional findings; the patient's condition improved, and she was able to be discharged home the following day.

At issue is the medical necessity of the inpatient stay.

The health plan's determination is overturned.

Yes, the requested inpatient hospitalization was considered medically necessary for this patient due to the duration of illness, findings at presentation, and diagnostic considerations. This is a young child who presented with 7 days of fevers (including being febrile in the ED) and additional findings that were concerning for infection. Kawasaki disease was a diagnostic consideration based on the physical examination (conjunctival injection, oral changes, cervical lymphadenopathy) and laboratory (elevated CRP) findings. Given the potential for adverse health consequences, an accurate diagnosis and prompt treatment with intravenous immunoglobulin (IVIG) are imperative to a diagnosis of Kawasaki disease. Thus, this patient required close monitoring and additional testing at the inpatient level of care in order to ensure the best medical outcome.