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

Patient is a teenager with past medical history significant for depression who presented to the emergency department with complaints of neck pain and dehydration.

Vitals on presentation included: Temperature-102.6.3 degrees F (Fahrenheit), Blood Pressure - 95/75, Pulse-111, Respirations -19, oxygen saturation 97% on room air. Laboratory values were notable for the following: white blood cells (WBC)-9.68, Hemoglobin (Hgb)-14.1, Hematocrit (Hct)-43.8, glucose-95, creatinine-0.7, erythrocyte sedimentation rate (ESR)-21, C reactive protein (CRP)-7.7

Patient was empirically started on intravenous antibiotics and Decadron. She tested positive for rapid Monospot. She was given pain medications which improved her symptoms. She received intravenous hydration, remained afebrile, hemodynamically stable, and clinically improved. She was discharged to outpatient management.

According to documentation, patient presented with upper respiratory illness-like symptoms. Otherwise, patient was hemodynamically stable with unremarkable laboratory results including a normal WBC. She tested positive for infectious mononucleosis. Patient had no evidence of serious complications of mononucleosis. Based on above findings, patient met criteria of observation level of management. Patient did not meet criteria for acute inpatient admission.

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 full hospital admission is not substantiated.