Diagnosis: cough, eye redness
Treatment: inpatient stay
the insurer denied the inpatient stay.
The health plan's determination is upheld.

This is the case of an infant female twin who presented to the emergency department (ED) with cough and congestion and eye redness. There was no fever or trauma or concern for foreign body. The patient is living at a shelter with her mother, twin brother, and 22 month old sibling. Child protective services were involved with this family.
ED vitals were T (temperature) 36.3oC, heart rate (HR) 138-151, respiratory rate (RR) 34-38, and O2 (oxygen) saturation 100% room air. Weight was 14lb (pounds). Exam noted left eye redness and reducible umbilical hernia, it was otherwise reassuring.

The requested inpatient admission was not medically necessary for this patient. However, the patient was at increased risk for poor outcomes due to housing instability (living in a shelter) and lack of alternative caregivers. Therefore, admission for observation would have been appropriate. This could have been done at a lower level of care.