Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency room (ER) with complaints of abdominal pain associated with nausea, vomiting and diarrhea. He had 4 episodes of emesis and 6-7 episodes of watery diarrhea prior to admission. He complained of pain to his umbilical area with associated nausea, vomiting and diarrhea in the ED. The last emesis was early afternoon but he continued to have copious diarrhea without control of his bowel. He stooled in his bed without realizing it in the ER. He had nonbloody stool that was foul smelling. The abdominal pain was relieved by stooling. His abdominal pain improved with Tylenol and Toradol.

The exam in the ER documented a well appearing child in no distress. He had mild tachycardia with a fever; the abdomen was soft and nontender. Capillary refill was less than (<) 2 seconds. An abdominal computed tomography (CT) scan was performed for concerns of appendicitis. The appendix was visualized and was normal but the patient was found to have acute colitis on the CT scan. He also met sepsis criteria on admission with a heart rate (HR) of 138, fever 104.4 degrees Fahrenheit and lactic acid of 2.7. A repeat lactic acid in the ED was 3.4. The complete blood count (CBC) and comprehensive metabolic panel (CMP) were unremarkable. Urine specific gravity (SG) was 1.017 with no ketones. He received 2 normal saline (NS) boluses, intravenous (IV) Zofran, Tylenol, Toradol and 1 dose of IV Zosyn in the ER. He had poor oral intake and was admitted for continued IV hydration and monitoring due to copious incontinence of stool and decreased oral intake the evening prior. The hospitalist saw the patient and patient was clinically well appearing with a low concern for sepsis, antibiotics were not continued at admission. The following morning the patient reported feeling well and his parents reported he was much improved. He had 3 episodes of watery, green diarrhea which was less frequent and less volume than previously. Repeat labs in the morning revealed lactic acid back to normal at 1.1. He ate some crackers for breakfast and had some tea with no vomiting. The family was anxious for discharge home. Blood cultures were pending, stool guaiac negative. He tolerated soup for lunch and was stable for discharge home on probiotics. The patient was advised to follow up with the primary medical doctor (PMD) in 1-2 days if the symptoms were not improved. Labs obtained after discharge showed a stool culture positive for Shigella confirming that the patient had infectious diarrhea which caused colitis.

At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was not medically necessary for this patient. This patient presented with a one day history of vomiting and diarrhea. His initial vital signs revealed a high fever and associated tachycardia but no physical signs of dehydration reported. There was no laboratory evidence to support dehydration. Electrolytes were within normal limits (WNL) and urine SG was 1.017 with no ketones. After ER management of IV Zofran x 1 and NS bolus, this patient arrived to the pediatric floor and was assessed by admitting physician as clinically well appearing with low concern for sepsis. There was no mention of a failed by mouth (PO) trial in the ER, just concern that he would not keep up with his stool output. There was no mention of PO intolerance. The patient did not have any further emesis or fever after admission to the hospital. He was discharged in less than 24 hours. His illness was not severe to require increased intensity of services that would qualify for inpatient admission. No highly technical or skilled care was ordered upon admission. Inpatient care was not needed.