Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever, diarrhea, vomiting
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The Inpatient admission was not medically necessary.

The patient is a male child with medical history significant for Dandy-Walker syndrome and aortic coarctation status post repair. He presented to the ED with multiple episodes of diarrhea, one episode of vomiting, refusal to drink, tactile fever, and no urine output in twelve hours. 

The patient's vital signs included temperature 37.7, heart rate 119, and respiratory rate 24. Examination was significant for being active in no distress, moist mucous membranes, regular heart rate and rhythm with strong pulses, non-tender abdomen, brisk capillary refill, and non-focal neurologic exam. Laboratory evaluation was significant for mild anemia (hemoglobin 33.1), normal glucose (76), and metabolic acidosis (CO2 [carbon dioxide] 18). He was treated with dextrose and a normal saline bolus, but had no urine output. 

The patient was admitted to the pediatric floor for further management of mild dehydration and acute vital gastroenteritis. Admission orders included cardiopulmonary monitoring, IV fluids, and antipyretics as needed. On hospital day two, he had multiple episodes of diarrhea. He also began complaining of abdominal pain. He remained active, was afebrile, and was urinating well. He was drinking but not eating. He remained on IV fluids with daily weights. By day three, his stool was starting to firm and he was drinking, but continued to refuse to eat. His diet was advanced and he began eating. Then, he no longer had loose stools, and was cleared for discharge.

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 five 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. Output (vomiting, diarrhea) limits the success of oral rehydration, prompting use of anti-emetic medications. 

This young male child with medical history of Dandy-Walker syndrome and repaired aortic coarctation presented to the ED with signs and symptoms consistent with mild dehydration. He was admitted for hydration and monitoring. The day after admission, he was drinking and voiding, but not yet eating solid food. He did not begin to eat solid food until he was started on the BRAT (bananas, rice, apple sauce, and toast (or tea)) diet, concurrent with his stool becoming more formed. While it was initially important to provide this child with parenteral hydration, he was drinking sufficiently to sustain himself and maintain good urine output by the second hospital day. He remained hemodynamically stable with no evidence of severe dehydration or sepsis. He did not require acute inpatient admission, and he could have been safely managed at a lower level of care, such as observation.