Diagnosis: Fever and sore throat
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female without significant past medical history. She was hospitalized with fever and sore throat that was thought likely to be related to a viral infection. The patient's vital signs were notable for temperature 101.3, pulse 103, normal blood pressure and respirations, and oxygen saturation 100% on room air. Labs were notable for white blood cell count 18, lactate 1.17, normal creatinine, negative COVID and influenza testing, urinalysis with trace leukocyte esterase. Notes indicate a diagnosis of "sepsis from unknown source." She was given fluids, antibiotics, and acetaminophen/Toradol. The patient had clinical improvement. Blood cultures were negative. She was evaluated by infectious disease consultant team. She was discharged on day #3 in stable condition with oral antibiotics.
The inpatient hospitalization was denied coverage by the health plan, who noted that the patient could have been managed in a lower level of care. The facility appealed the denial, arguing that the patient's workup and treatment "could not have been done in
the outpatient setting. Clearly there was no feasible way to discharge the patient." The health plan upheld the denial, noting again that the medical records showed that the patient could have been placed in observation and monitoring. This denial is being appealed.

The inpatient admission was not medically necessary.

The documentation does not reflect clinical findings that support the need for acute inpatient level of care per the medical literature and evidence-based guideline entitled "Sepsis and Other Febrile Illness, without Focal Infection (M-160)" from MCG (Milliman Care Guidelines) 26th edition. Specifically, there was no evidence of hemodynamic instability, bacteremia, hypoxemia, altered mental status, failure of outpatient treatment, new coagulopathy, persistent tachypnea, persistent dehydration, evidence of end organ dysfunction that is persistent or severe, core temperature less than 95, parenteral antimicrobial regimen that could only be performed on an inpatient basis, or isolation that could not be performed in the outpatient setting. This patient was hemodynamically stable, had no critical derangement in labs, had quick improvement with initial treatment, and was able to be transitioned to oral antibiotics for discharge within the observation timeframe. Treatment could have safely and effectively been provided at a lower level of care. Therefore, the inpatient hospitalization was not medically necessary.