Diagnosis: Ear drainage
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The Inpatient admission was medically necessary.

The patient is a male infant with maternal history significant for GBS (Group B streptococcus) positive and chronic hepatitis B status post immunoglobulin and vaccine. He presented to the ED because of clear drainage from his right ear. He had no fevers and was otherwise well. He had not yet received his two month vaccines.

The patient's vital signs included temperature 99.6, heart rate 146, respiratory rate 35, with 100% saturation in room air. Examination was significant for well appearance, no distress, clear discharge from the left ear, perforated left tympanic membrane with thick white discharge and clear liquid discharge, bulging right tympanic membrane with no perforation or discharge, no nasal discharge, moist mucous membranes, clear lungs, regular heart rate and rhythm, benign abdomen, and non-focal neurologic exam. He was diagnosed with bilateral suppurative acute otitis media with left perforation, with concerns for bacteremia/meningitis due to age and unvaccinated status. Full sepsis work-up was performed including lumbar puncture. Laboratory evaluation was significant for negative urinalysis, thrombocytosis (platelets 587K), hyperkalemia with no visible hemolysis (potassium 6.2), metabolic acidosis (CO2 [carbon dioxide] 18), and elevated lactate 4.6 on venous blood gas. Cerebrospinal fluid gram stain revealed 3+ white blood cells with no organisms. Cultures of urine, blood, cerebrospinal fluid, and ear drainage were all obtained and were pending. Chest x-ray was unremarkable.

The patient was given a dose of ceftriaxone prior to admission to the pediatric floor. Admission orders included continuation of ceftriaxone pending culture results. ENT (otolaryngology) was consulted, performing a deep swab that was positive for Strep pyogenes. Urine, blood, and spinal fluid cultures all remained negative. By hospital day three, the ear drainage had improved sufficiently, that in conjunction with negative cultures, he was deemed stable for discharge, to follow-up with ENT and to complete a course of antibiotics with amoxicillin and ofloxacin drops.

This infant did not present with fever, rather with unilateral ear drainage. On exam, he was found to have bilateral suppurative otitis media with unilateral perforation. Because of the risk of serious bacterial infection due to hematogenous spread in such a young infant with suppurative acute otitis media, full septic work-up was warranted with management based on guidelines for acute febrile illness as above. Treatment with parenteral antibiotics pending culture results was medically necessary, consistent with current recommendations. Lower level of care would not have been safe or appropriate in this case. The full duration of his hospital stay was medically necessary at an acute inpatient level of care.