Diagnosis: Fever

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient has sickle cell disease (SCD) presenting with fever and URI (upper respiratory infection) symptoms concerning for sinusitis. The medical record indicates that the patient was non-toxic appearing, labs were "otherwise reassuring" and vital signs were unremarkable except for fever, and chest x-ray was clear.

Empiric antibiotic coverage for sickle cell patients with fever is standard of care based on their relative immune-compromised state. However, indications for hospitalization instead of ambulatory management include very young age, very high fever, high white blood cell count (WBC) or toxic appearance. The patient did not meet these criteria for high risk of sepsis, and therefore, it is unclear from the medical record why hospitalization rather than ambulatory management was deemed necessary. As such, denial from the health care plan was reasonable.

As indicated above, the patient does not appear to have met high risk criteria to support the need for inpatient management rather than ambulatory management. Reference 2 notes, "Admission Criteria Consideration for admission should be a dynamic process taking into account reassessment of patient over time and in response to intervention. However, there are some instances in which admission is necessary or strongly encouraged: 1. Toxic, ill appearing or clinically suspected ACS [acute coronary syndrome] 2. Child is under six months old or not up to date on vaccinations 3. Hemoglobin and /or reticulocyte count well below baseline or WBC (white blood cell) > 30,000."

As indicated in Reference 3, "A well-appearing febrile child with SCD may be managed as an outpatient after blood is obtained for bacterial culture and parenteral antibiotics are administered, provided there are no other reasons for admission and the patient is able to return promptly for worsening condition or for growth of a pathogen from their blood culture."

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for an inpatient admission is upheld. Medical Necessity is not substantiated.