Diagnosis: fever
Treatment: inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is overturned.

The patient is a boy who presented with lethargy.
He was well until a week prior to presentation when he developed fever. He was receiving acetaminophen and ibuprofen at home, but his fevers continued and were up to 103 F (Fahrenheit). He was seen by his primary doctor and was diagnosed with otitis media and prescribed amoxicillin. He had been receiving amoxicillin as directed, but he continued to be ill and developed decreased activity and decreased interactions with others. He wasn't getting up or walking around, and he also had decreased oral intake. His fevers had resolved, and he had no upper respiratory symptoms. Due to the persistence of his symptoms, he was brought to the emergency department for care.

The inpatient hospital admission was medically necessary for this patient.
Children who are suspected of having bacterial meningitis or other serious bacterial infections should be admitted to the hospital for intensive management and monitoring. This is a young boy with a history of fever who presented with lethargy. He was hypothermic and had delayed capillary refill at the time of presentation. He required a prompt work up and initiation of treatment for potentially severe infection including concern for partially treated meningitis. This requires inpatient care due to the potential spread of infection and clinical deterioration.
The decision making at the time of admission for this patient was consistent with his young age, the presence of lethargy and concern for serious bacterial infection, and the need for prompt evaluation and initiation of therapy along with close monitoring for potential deterioration of clinical status.