Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting

Treatment: inpatient stay rendered

The insurer denied coverage for inpatient stay rendered

The denial is upheld.

The patient is a male with a past medical history notable for incomplete trisomy 16, developmental delay and horseshoe kidney that was referred to the Emergency Department for assessment and management of non-bilious, non-bloody vomiting x 1 day, lethargy, decreased oral intake and possible abdominal pain. His urine output was decreased. There was no associated fever, GI (gastrointestinal) bleeding, diarrhea, weight loss or dysuria. The patient was seen by his provider and his white blood count was 23.9 leading to the referral. The patient's vitals on arrival were notable for HR (heart rate) 120 Temperature 97.1 Fahrenheit, RR (respiration rate) 26, BP (blood pressure) 101/67 and room air oxygen saturation of 99% (percent). Admitting weight was 13.8 kilograms and height was 91.5 centimeters. Physical exam showed a sleepy but arousable ill-appearing, pale, diaphoretic male. He had moist mucus membranes with delayed capillary refill and decreased skin turgor. Lungs were clear with normal effort. Cardiac exam was notable for a systolic heart murmur. Abdomen exam was soft. There was no associated pain, organomegaly, distension, rebound, guarding or masses. There was no rectal exam reported. A gastroenterology suspects a foreign body in the duodenum given the history of the patient eating chicken wings and playing with raw dough the day prior to symptoms. An UGI (upper gastrointestinal series) with small bowel follow-through was unremarkable. He received intravenous pantoprazole on. His diet was advanced that he tolerated. On he passed a rubber toy and chewing gum like substance via his rectum. He received no pain medications or additional anti-nausea agents. No repeat laboratories were obtained. He was discharged home for outpatient follow-up.
 
This child appears to have self-limited vomiting with mild dehydration that resolved by the time of admission to the inpatient setting associated with an unrecognized foreign body ingestion. He did appear significantly dehydrated on presentation that improved with modest fluid resuscitation. He did not have severe intractable vomiting as stated in the appeal. In accordance with a review of the approach to nausea and vomiting in infants and children from UpToDate (see attached pdf file) the reasons to admit such an individual would include signs of significant dehydration poorly responsive to intravenous hydration in the Emergency Department, significant weight loss, profound lethargy, hemodynamic instability, significant electrolyte imbalance, demonstrated oral hydration intolerance to oral challenge, poorly controlled pain with an oral pain medication regimen, concerning physical exam findings for a surgical process or findings consistent with significant blood loss or bowel obstruction. He did not meet any of these criteria to merit the inpatient setting. His blood pressure was normal for age and his heart rate on discharge was higher than on presentation. Although he did have some abdominal discomfort during the admission, he did not require pain medications. He never had bowel obstruction suspected by imaging or physical exam as stated in the appeal and there were no surgical indications as noted in the surgical and gastroenterology consults. 
 
The documentation of this child's appearance and vitals would indicate mild/moderate dehydration on presentation that resolved with modest intravenous resuscitation within hours of his arrival. After an evaluation excluded dangerous conditions, he was merely observed with multiple negative assessments and safely discharged on oral fluids with outpatient follow-up. He actually received no acute care after admission to merit reimbursement at that level. His leukocytosis with a normal CRP (C-Reactive Protein) did not suggest a bacterial process and no antibiotics were administered. In regard to the acute inpatient admission the determination by the carrier that the admission was not medically necessary was correctly applied, objective, clinical valid, compatible with established principles of health care and flexible enough to permit justified variation. This decision was rendered based on review of the hospital record and the attached reviews from UpToDate summarizing the approach to nausea and vomiting in children and dehydration in children in cited above.

The insurer's denial of coverage for inpatient admission should be upheld. Medical Necessity is not substantiated.