Diagnosis: Hypoglycemia
Treatment: Inpatient admission
The insurer denied coverage for an inpatient admission
The denial is upheld

The patient was brought into the emergency department (ED) by the mother for evaluation of fever and congestion for two days and cough with nasal discharge for two months. Per the patient's mother, the patient had been lethargic and had trouble breathing at night, and a rash was noticed on patient's left leg. While in the ED, the rash spread to the patient's chest, arms, legs, and soles of feet. Laboratory results indicated hypoglycemia and imaging demonstrated generalized lung haziness without focal pulmonary consolidation. The patient received a dextrose bolus x 2 in the ED and was started on intravenous (IV) antibiotics for sinusitis. The patient was admitted for dehydration in the setting of acute viral illness and started on IV fluids. The patient's oral intake improved, the patient remained afebrile, and their glucose levels normalized. The patient was cleared for discharge with outpatient follow-up.

Once the patient was on the floor, the history and physical documents that the "patient was babbling and cooing", "walking around in the room". Clearly in no distress. The ED temperature was 100.2 degrees Fahrenheit. The initial lethargy was attributed to hypoglycemia which was easily treated with a dextrose infusion. There was no concerning diagnosis such as pneumonia, respiratory distress, hypoxia (oxygen saturations > 95 %) and severe dehydration. The basic metabolic panel (BMP) showed a bicarbonate of 17 which was low but still > 15. There was no need for more than 2 boluses. No vasopressors needed. No need to use noxious stimuli to arouse the patient (the lethargy was responding to Dextrose). No need for oxygen or continuous positive airway pressure / bilateral positive airway pressure (CPAP /BiPAP). No need to escalate the therapy while on the floor. There was no evidence of Kawasaki. The Covid test was negative. There was no sepsis and no shock. The working diagnosis was hypoglycemia and sinusitis (treated with Unasyn). If one were to take the Pediatric early warning scoring tool (PEWS) while the patient was on the floor, the PEWS would have been 0 which is desirable. The patient could have been treated in observational status.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is not substantiated.