Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female teen that presented to the ED (emergency department) with two-day history of vomiting. She had been seen at Urgent Care earlier in the day and given an anti-emetic without relief. She was vomiting in the triage area. She denied fever and diarrhea. 

The patient's vital signs included temperature 36.6, heart rate 67, respiratory rate 22, and blood pressure 119/83. Examination was significant for right upper quadrant abdominal tenderness. Laboratory evaluation was significant for metabolic acidosis with CO2 (carbon dioxide) 16.6, mild hypokalemia with potassium 3.4, hyperglycemia with glucose 138, negative CRP (C-reactive protein), mildly decreased TSH (thyroid stimulating hormone) 0.35, leukocytosis with WBC (white blood count) 17.43K (thousand), and urinalysis with ketones and specific gravity 1.031. Ultrasound revealed possible increased echogenicity of the portal triad which may indicate an infectious cause such as hepatitis. 

The patient was treated with Zofran and IV (intravenous) fluids and admitted for persistent vomiting. Admission orders included nothing by mouth, IV (intravenous) fluid, Zofran once, routine Pepcid, and repeat lab studies. She did well overnight, so IV (intravenous) fluids were decreased, and she was allowed a clear liquid diet. Repeat metabolic panel revealed CO2 (carbon dioxide) improved to 17.1. She reported some anxiety so was referred to outpatient therapy. She was able to tolerate the advancing diet, so was deemed stable for discharge.

No, the Inpatient Admission was not medically necessary.

Acute gastroenteritis is a major problem worldwide, representing one of the leading causes of morbidity and mortality in children. There are an estimated 2.5 million deaths each year attributable to gastroenteritis in children under the age of year years. Most cases are caused by viruses, are self-limited, and require supportive treatment. According to the World Health Organization, oral rehydration therapy is the treatment of choice, particularly where diarrhea is the prominent feature and dehydration is mild to moderate. Intravenous rehydration is indicated when oral rehydration fails or when output is excessive. Vomiting limits the success of oral rehydration, prompting use of anti-emetic medications. Hospitalization may be necessary for those that do not respond to oral hydration and anti-emetic treatment, as well as those with severe dehydration.

This young woman presented to the ED (emergency department) with persistent vomiting after failing outpatient management at an urgent care center with oral anti-emetic therapy. She failed an attempt to tolerate anything by mouth in the ED (emergency department) as well. While it was reasonable to monitor her in the hospital overnight with IV (intravenous) hydration, she was overall hemodynamically stable, with no evidence of severe dehydration or impending shock, and no significant underlying medical conditions. She did not require acute inpatient admission and could have been safely managed at a lower level of care.