10mo. with Herpangina and Dehydration

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

Denial Type: Medical Necessity Concurrent
Age: 10 months
Gender: Female
Insurance: Medicaid Replacement (MCO)
Length of Stay: 43 Hours
Reason for Being Hospitalized: Herpangina with continuing fevers to 105.2, poor oral intake, tachycardia to 178.
Pertinent Past Medical or Maternal History: None

Hospital Course:

10-month-old female was brought to the ED for fever, emesis, and poor oral intake. Her initial vital signs showed temperature 102.5F and tachycardia to 178. Physical exam revealed otitis media and herpangina. The patient received I.V. fluids and IV ceftriaxone. On the 2nd day of hospitalization, she had persistent fever to 101.8F, tachycardia to 162, and poor oral intake requiring continued I.V. fluids. The patient defervesced on 3rd hospital day, her oral intake improved, and the patient was discharged.

Appeal Strategy:

On Peer to Peer pointed out that fever, tachycardia, and poor oral intake with need for I.V. fluids persisted beyond an Observation period. Know your payer’s criteria; this payer uses MCG which defines obs as 24 hours and this stay exceeded that.