Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple Episodes Of Vomiting With Belly Pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male child with medical history significant for febrile seizures. He presented to the ED (emergency department) with three-day history of recurrent vomiting (about ten episodes daily) and poor oral intake with decreased urine output. He had no fevers and no diarrhea, but his mother reported some epigastric abdominal pain with emesis. The pediatrician prescribed Zofran, but the child was unable to tolerate it.

The patient's vital signs included temperature 37.5, heart rate 140, blood pressure 95/77, and respiratory rate 22. Examination was significant for no acute distress, tired dehydrated appearance, dry mucous membranes, tachycardia, clear lungs, non-tender abdomen with no guarding or rebound, good perfusion, and non-focal neurologic exam. Laboratory evaluation revealed venous pH (potential of hydrogen) 7.28 with venous bicarbonate 13, CO2 (carbon dioxide) 10, urinalysis with specific gravity greater than 1.030, and ketonuria. His bedside glucose was 45.

The patient's glucose was treated with D10 (10% dextrose) bolus. He was also treated with two IV (intravenous) fluid boluses and Zofran prior to admission for further management. Admission orders included IV (intravenous) fluids, Zofran as needed, strict ins/outs, vital signs every four hours, repeat metabolic pane, and oral intake as tolerated. Repeat blood work the next day noted improvement in CO2 (carbon dioxide) to 17 with normal glucose 82. He remained hemodynamically stable, able to tolerate food and fluids sufficiently to discharge home.

Yes, the Inpatient admission was medically necessary and appropriate.

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. 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 male child presented to the ED (emergency department) with significant dehydration from refractory vomiting over the course of three days, with dry mucous membranes, decreased urine output, and decreased activity. Laboratory evaluation revealed severe hypoglycemia and significant metabolic acidosis. He was treated appropriately in the ED (emergency department) with parenteral fluids and dextrose, admitted because of the severity of his dehydration and concern for further vomiting and metabolic decompensation. While he remained hemodynamically stable and was able to advance his diet without ongoing vomiting, the level of care that he received was most consistent with acute inpatient management, despite the brevity of his hospital stay.