1 Year-old with MIS-C

Submitted by Barbara Abrams, MD, JD, CHCQM-PHYADV
Physician Advisor, Orlando Health 

Denial Type: Medical Necessity Concurrent
Insurance: Medicaid Replacement (MCO)
Length of Stay: 60 hours
Reason for Being Hospitalized: Fever, rash, decreased oral intake.
Pertinent Past Medical or Maternal History: None 

Hospital Course:

This 1 year old was febrile to 101.5 on admission. Labs included a WBC count of 20.2, C-Reactive Protein 59.6, Sed Rate 95. D-Dimer was 1918 on admission and 2069 on hospital day #2. ANA was positive. Covid-19 PCR negative. There was a concern for an inflammatory process with elevated CRP and ESR and for thromboembolism given significantly elevated D-Dimer levels.

The child remained fussy on day #2. Febrile to 100.8. Rash treated with Benadryl. On day #3 patient was afebrile, rash was resolving, and oral intake improved. Patient discharged.

Appeal Strategy:

This child was admitted during a COVID-19 surge. Due to the current COVID-19 pandemic, fever and rash in a child with elevated D-Dimer levels is suspicious for MIS-C (Multisystem Inflammatory Syndrome—Children) even with negative COVID PCR.

Takeaway - Know current diagnostic criteria (and cite if possible)