Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Respiratory Syncytial Virus and Adenovirus, Vomiting, Diarrhea
Treatment: Inpatient hospital admission
The insurer has denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a female infant born full term that presented to the emergency department (ED) via Emergency Medical Services (EMS) a few months old with a two-day history of cough, rhinorrhea, three episodes of vomiting, and over ten episodes of diarrhea each day. She had no fevers. Two weeks prior, she had a cough and decreased feeding. She had been seen already by urgent care and was diagnosed with an acute viral illness. The examination was significant for nasal discharge, dry mucous membranes, clear lungs with no evidence of distress, benign abdomen, normal capillary refill, mottled skin, and a non-focal neurologic exam. Her stool was guaiac positive. She was able to tolerate a bottle but continued passing diarrhea stool with one episode of vomiting. She was treated with two normal saline boluses. Laboratory evaluation was completed and was significant for a white blood cell count (WBC) of 15.6 thousand (K), 61% (percent) lymphocytes, 617K platelets, a carbon dioxide (CO2) of 16, a glucose of 95, and a respiratory panel positive for adenovirus and respiratory syncytial virus (RSV). A stool polymerase chain reaction (PCR) was also sent which was positive for adenovirus F. She received two fluid boluses and was monitored in the ED over seven hours but had minimal urine output and continued gastrointestinal (GI) losses. She was admitted for further management. Admission orders included maintenance intravenous (IV) fluids, strict ins/outs, nebulized saline as needed with suctioning, and slow advancing feeds.

When she arrived on the pediatric floor, her IV was no longer patent. Numerous attempts at replacement were unsuccessful. A nasogastric tube was placed in the middle of the night, and, once position was confirmed, she was given Pedialyte as a continuous infusion. She tolerated this without vomiting. Over the course of the day, she was able to bottle-feed with no vomiting. She was deemed stable for discharge to follow-up with her pediatrician in two to three days.

At issue is the medical necessity of an inpatient hospital admission.
I uphold the health plan's determination, in whole.

The inpatient hospital admission was not medically necessary for this child.

Acute gastroenteritis is a major problem worldwide. 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 and/or ongoing fluid losses that cannot be successfully managed with oral rehydration. 

This young infant presented with mild upper respiratory infection (URI) symptoms, vomiting, and diarrhea. She was significantly dehydrated clinically and by laboratory evaluation. She had minimal urine output while being monitored in the ED with ongoing losses, so she was admitted for further hydration. She did well overnight with no further vomiting. She was able to tolerate slowly advancing feeds and was subsequently deemed stable for discharge. While it was reasonable to monitor her in the hospital for adequate intake and ability to keep up with losses, she was overall hemodynamically stable with no evidence of impending sepsis or shock. She did not require acute inpatient admission and could have been safely managed at a lower level of care.