Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Viral gastroenteritis
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld
Infant with a past medical history notable for prematurity (28-week gestation), patent foramen ovale, patent ductus arteriosus, atrial septal defect, bronchopulmonary dysplasia, retinopathy of prematurity and chronic feeding difficulties that presented to the Emergency Department (ED) for vomiting, non-bloody watery stools decreased oral intake and fatigue. There was no associated fever, cough, congestion, gastrointestinal (GI) bleeding, known weight loss, sick contacts, pain or dysuria. The infant was still making wet diapers. The patient's vital signs on arrival were notable for Temperature (T) 37.5 Celsius, Heart Rate (HR)156 (crying and kicking), Blood Pressure (BP) 136/110, Respiratory Rate (RR) 30, and room air oxygen saturation of 98 percent (%). The weight was 7.785 kilograms (prior weight 4/19/23 was 7.755). Physical exam showed an irritable child in no apparent distress (NAD). The patient had moist mucus membranes with normal capillary refill (<2 seconds (Less than 2 seconds)). Lungs were clear with normal effort, cardiac exam was unremarkable, abdomen exam was soft, there was no associated pain, organomegaly, distension, rebound, guarding or masses, there was no rectal exam reported. Laboratory testing showed sodium 140, potassium 4.5, chloride 108, bicarbonate 19, blood urea nitrogen (BUN) 14, creatinine 0.44, glucose 78, white blood cell (WBC) 22.9k (22.9 thousand) without a left shift (neutrophils 13%), hemoglobin 13.4, platelet 362, albumin 4.3, bilirubin 0.4, aspartate aminotransferase (AST) 48, alanine transaminase (ALT) 31, alkaline phosphatase (AP) 227, C-reactive protein (CRP) 0.2, and lipase 14. No imaging was performed. The patient received one 20 cubic centimeter (cc)/kilogram (kg) Dextrose 5% (D5) normal saline bolus (no details noted) followed by D5 normal saline at 31cc/hour. An electrocardiogram (EKG) at 18:43 was notable for HR 118. The decision to admit for observation and hydration occurred for acute gastroenteritis and dehydration. The patient had 3-4 additional loose stools. IV fluids were lowered to 15cc/hour and stopped once tolerating oral intake and hydration. A gastroenterology consult recommended supportive care, GI polymerase chain reaction (PCR), stool alpha 1 antitrypsin, stool culture and Pediasure. 
 
This child appears to have a viral gastroenteritis (loose stools, intermittent self-limited vomiting) and minimal dehydration that resolved by the time of admission to the inpatient setting. The patient was able to tolerate oral rehydration but seemed the amount appeared inadequate compared to his loses. In accordance with a review of the approach to acute viral gastroenteritis in resource-rich countries in infants and children from UptoDate authors conclude the following:

Summary ad Recommendations
-	Acute viral gastroenteritis usually is self-limited. It is treated with supportive measures (For example (eg)), fluid repletion and unrestricted diet). No specific antiviral agents are available for the treatment of acute viral gastroenteritis.
Volume depletion is most objectively measured as a change in weight from baseline. Acute loss of body weight reflects the loss of fluid, not lean body mass; thus, a 2 kilogram (kg) weight loss should reflect the loss of two liters of fluid.

The documentation of this child's appearance and vitals at presentation would indicate minimal to mild dehydration that resolved with intravenous resuscitation within hours of his arrival and prior to inpatient admission. The patient's laboratory abnormalities were not critical and would be expected to correct with fluid resuscitation followed by oral rehydration therapy. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient hospital admission is not substantiated.