Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Viral gastroenteritis.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

 
Patient was a child with a past medical history of poor weight gain x 1 year (work-up included normal thyroid testing, negative celiac panel, normal B12/folate levels) and macrocytosis that presented to the Emergency Department complaining of intermittent non-bilious, non-bloody vomiting x 2 episodes in the last 24 hours, decreased oral intake of solids and intermittent abdominal pain x 2 days. Of note, the patient was tolerating water and juice. There were no associated fevers, diarrhea, constipation, cough, rhinorrhea, congestion or difficult breathing. There were no sick contacts. Urine output was normal. The patient's vitals were notable for Pulse 106, Blood Pressure 101/57, Temperature 36.6 degrees C, Respirations 23 and room air oxygen saturation of 100%. Physical exam showed an ill appearing, pale child. She had dry mucus membranes, cracked lips and normal capillary refill. Lungs were clear with normal effort. Cardiac exam was unremarkable. Abdomen exam was soft. There was no associated pain, organomegaly, distension, rebound, guarding or masses. There was no rectal exam reported. Admitting laboratories were notable for sodium 131, potassium 4.9, bicarbonate 16, Blood urea nitrogen (BUN) 17, creatinine 0.59, glucose 47 (point of care glucose 114), white blood count 9.1 with left shift (76% neutrophils, no bands), hemoglobin 12.2, platelets 514,000, amylase 54, lipase 20, vit D 25 -28.3, ferritin 37.5 and a normal liver profile. Nasal swabs were negative for Influenza A/B, Respiratory syncytial virus (RSV) and Covid. Urinalysis was notable for specific gravity greater than (&gt;)1.030, pH 5.5 and dip + for trace protein and large ketones. 

After Zofran she tolerated feeds without further vomiting and IV fluids were weaned. She remained afebrile the entire admission and received Pepcid orally for reflux. 

In accordance with a review of the approach to acute viral gastroenteritis in resource rich countries in infants and children from UpToDate the reasons to admit such an individual would include signs of significant dehydration poorly responsive to intravenous hydration in the Emergency Department, significant weight loss, profound lethargy, hemodynamic instability, significant electrolyte imbalance, demonstrated oral hydration intolerance to oral challenge, poorly controlled pain with an oral pain medication regimen, concerning physical exam findings for a surgical process or findings consistent with significant blood loss or bowel obstruction. She did not manifest any of these criteria to merit the inpatient setting. Her vomiting was not persistent and never recurred after a single oral dose of Zofran. Her weight fluctuations during the admission may have been secondary to differences in scales as she left with a lower weight than on admission despite intravenous hydration.
 
The documentation of this child's appearance and vitals would indicate mild dehydration on presentation that resolved with modest fluid resuscitation and maintenance fluids 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital admission is not substantiated.