Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COVID-19

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission
The denial is upheld

Patient was a female with a benign past medical history that presented to the Emergency Department for assessment and management of fever (101 degrees axillary), nasal congestion, non-bilious, non-bloody vomiting (secondary to congestion), fatigue, decreased oral intake (solids) and decreased wet diapers x 2 days. Of note both parents were recently Covid infected, and the mom wanted the child tested. She had 3 wet diapers in the last 12 hours and 2 stools. There was no associated GI (gastrointestinal) bleeding, diarrhea, weight loss or dysuria. The patient's vitals on arrival were notable for HR (heart rate) 123 Temperature 98.2 F (Fahrenheit), Respiratory Rate 25, Blood Pressure 101/66, and room air oxygen saturation of 98%. Admitting weight was 12.5 kilograms. Physical exam showed an arousable well-appearing child in no apparent distress. She had dry mucus membranes and nasal congestion with normal capillary refill and normal skin turgor. Lungs were clear with normal effort. Her cardiac exam was unremarkable. Her 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 136, potassium 4.5, bicarbonate 12, BUN (blood urea nitrogen) 17, creatinine 0.3, white blood cell 11.3 with a left shift (neutrophils 79%, no bands), hemoglobin 12.6, platelet 234, lactate 2.7, albumin 4.5, AST (aspartate traminase) 50, ALT (alanine transaminase) 18, AP (alkaline phosphatase) 193 and lipase 11. Serum glucose was 65 that rose to 116 after D (dextrose)10% W (water) 65 (cubic centimeters) cc x 1. No urinalysis was submitted for review. Nasal viral washings were positive for Covid. 

A reason given to justify the inpatient setting was significant dehydration. In regard to her volume status in a second review of dehydration in children from UpToDate (attached pdf) the following elements summarize the assessment of the degree of dehydration: Degree of dehydration - Fluid repletion guidelines for children with gastroenteritis by the American Academy of Pediatrics, Centers for Disease Control, and the World Health Organization are based upon the degree of volume depletion. As a result, it is important to be as accurate as possible when assessing the degree of dehydration. Severe hypovolemia requires rapid isotonic fluid resuscitation, although oral rehydration may be sufficient for mild to moderate hypovolemia.

Volume depletion is most objectively measured as a change in weight from baseline. Acute loss of body weight reflects the loss of fluid, not lean body mass; thus, a 2 kg (kilogram) weight loss should reflect the loss of two liters of fluid.

The documentation of this child's appearance and vitals would indicate mild dehydration on presentation that resolved with intravenous resuscitation within hours of her arrival. After initial fluid boluses, glucose infusion and a single dose of Zofran she tolerated oral hydration with maintenance of her serum glucose. She actually received no acute care after admission to merit reimbursement at that level. Her Covid symptoms (fever, congestion) were mild and never caused compromised breathing as suggested in the appeal. In regard to the acute inpatient admission the determination by the carrier that the admission was not medically necessary was correctly applied, objective, clinical valid, compatible with established principles of health care and flexible enough to permit justified variation. This decision was rendered based on review of the hospital record and the attached reviews from UpToDate summarizing the approach to nausea and vomiting in children and dehydration in children in cited above.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the full hospital admission is upheld. Medical Necessity is not substantiated.