Pediatric Sepsis: The Denial Dilemma
The Rise of RSV and Influenza
The United States is in the midst of a nationwide outbreak of RSV and Influenza A infections. These viruses can cause viral pneumonia in children (defined by ages birth to < 18 years old). We have seen reports both on national and perhaps your local news reporting limited availability of Pediatric ICU beds. Why the increase? For the last two years children have had limited exposure to RSV and Influenza because of the COVID 19 pandemic and social distancing. This has changed now that children are back in school, in public places and around more people. Exposure has increased for these reasons as well as the decrease or limited use of masks which has led to the return of RSV and Influenza infections in children.
Diagnosis Criteria
The most severe complications of these infections are acute respiratory failure and sepsis. The criteria to establish a diagnosis of sepsis in children were published in 2005 which is still in use today. Children are not small adults and there are age specific ranges for heart rate, respiratory rate, white blood cell count and systolic blood pressure. In working with our clients with pre-bill chart reviews many are reporting payment denials for sepsis in children. The insurance companies are using the Sepsis- 3 clinical criteria to validate the diagnosis of sepsis in children. However, Sepsis-3 was developed to define sepsis in adults, 18 years and older.
If you receive a clinical validity denial for payment of a claim with a diagnosis of pediatric sepsis review the denial letter for the clinical criteria the insurance company is applying. If the insurance company is applying the Sepsis-3 criteria, defend your position by pointing out the criteria do not apply to the pediatric population. Keep your Physician Advisors in the loop for they need to be aware of this inappropriate use of the Sepsis-3 criteria when they engage in peer-to-peer encounters with the insurance companies.
References
Below are some key references that you can use to support your denial defense when the Sepsis-3 criteria are applied to deny payment for a diagnosis of pediatric sepsis:
*Statement from one of the three original articles that described Sepsis 3
“A retrospective cohort study was performed among adult encounters (age ≥ 18 years) with suspected infection.”
Assessment of Clinical Criteria for Sepsis
JAMA. 2016; 315(8):762-774. doi: 10.1001/jama.2016.0288JAMA. 2016; 315(8):762-774.
*Definition of pediatric sepsis
Pediatric Critical Care Medicine 2005 Vol. 6, no.1 page 2-8