Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastrointestinal
Treatment: Inpatient stay
The health plan denied the inpatient stay as not medically necessary. 
The denial is overturned in whole.

The patient had a history of poor weight gain who presented to the emergency department due to poor oral feeding for several weeks.
Patient had been having vomiting episodes about 2-3 times per day over several months, and was being treated with omeprazole by a gastroenterologist for these symptoms. The vomiting had improved, however 3 weeks prior to admission patient began to refuse eating all solid foods. Patient was not opening  mouth and not feeding self. Then, 5 days prior to admission the patient developed a temperature to 102F as well as a dry cough and post tussive emesis. Patient was seen the next morning in the emergency department and was diagnosed with a viral infection and sent home. After that the patient had decreased wet diapers and decreased intake of solid foods. Patient was subsequently seen by the gastroenterologist and then referred to the emergency department due to persistence of these symptoms.
In the emergency department the patient was found to have a temperature of 99.2 Fahrenheit. Laboratory values were obtained, and patient  was given 2 boluses of normal saline. Patient continued to not tolerate oral feedings at that time and was refusing to eat or drink in the emergency department. There was concern for dehydration as well as malnutrition. The laboratory values were obtained and were significant for a low prealbumin of 15.5 mg/dL, suggesting inadequate nutrition. The patient was subsequently admitted to the hospital for intravenous rehydration and nutrition consultation as well as speech swallow evaluation due to poor oral feeding for multiple weeks in the context of chronic feeding difficulties.
The past history is significant for premature birth at 33 weeks. Patient was in the neonatal intensive care unit for 3 weeks after birth and required G-tube support for 2 weeks due to feeding difficulty.
Upon admission the patient was started on maintenance intravenous fluids.They were able to discontinue the intravenous fluids due to improvement in  oral intake. Patient was then offered PediaSure which was tolerated without complication. The patient also demonstrated the ability to eat some rice cereal as well as baby foods. The gastrointestinal team was consulted and felt that the patient appeared improved and was gaining weight reasonably based on the growth curve. They felt the patient could be further managed as an outpatient, and therefore  was discharged home with follow-up with the gastroenterologist in 2-3 weeks.

This is a very young patient who presented with acute on chronic poor feeding. Patient had been evaluated by a gastroenterologist in the past, and over the 3 weeks prior to admission was refusing to eat any solid food. These symptoms then were exacerbated by a febrile illness with cough and emesis. The patient had decreased wet diapers and further decreased intake of solid foods at that time. The patient was appropriately referred to the emergency department by the gastroenterology specialist. In the emergency department the patient continued to refuse to eat, and therefore required inpatient admission for evaluation of food refusal and treatment for dehydration. Patient had a complicated past history with premature birth and feeding difficulty.
The decision making at the time of admission for this patient was consistent with her young age, the presence of chronic feeding difficulties that had recently worsened to complete refusal of oral foods over the past 3 weeks, and the need for prompt evaluation along with intravenous hydration and assurance of appropriate nutrition.