Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dehydration.
Treatment: Inpatient admission. 
The insurer denied coverage for an inpatient admission. 
The denial is upheld.

This patient with a past medical history notable for autistic spectrum disorder and speech delay presented to the emergency department for assessment and management of a dry cough, mild nasal congestion, and for non-bilious, non-bloody vomiting over the last 2 days He also had decreased oral intake, decreased urine output and intermittent low-grade fevers up to 100.2F (Fahrenheit). There was no associated GI (gastrointestinal) bleeding, known weight loss or dysuria. The patient's vitals on arrival were notable for a heart rate of 130, blood pressure 114/74, temperature 99.6 F, respiratory rate 28, and room air oxygen saturation of 97% (percent).  Admitting weight was 14.5 kilograms and his height was 105 centimeters. Of note was that the patient was seen the day prior in the same emergency department and treated with Zofran and discharged on Pedialyte. 
 
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. He did not meet any of these criteria to merit the inpatient setting. Returning to the emergency department the day after a single dose of Zofran does not constitute failed outpatient management. His heart rate was minimally elevated for his age and his weight dropped 0.3 kilograms between presentations that corrected by the time of admission. His metabolic acidosis was likely secondary to ketosis and diarrheal losses rather than tissue hypoperfusion.
 
A second reason given to justify the inpatient setting was significant dehydration in regard to volume status. 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.

The documentation of this child's appearance and vitals would indicate mild/moderate dehydration on presentation that resolved with modest intravenous resuscitation within hours of his arrival. His laboratory abnormalities were not critical and would be expected to correct with fluid resuscitation followed by oral rehydration therapy. He appeared to be admitted more for his recent presentation the day prior without intervention rather than the severity of his second acute presentation. After admission he was merely observed with both intravenous and oral fluids, and safely discharged on oral fluids with outpatient follow-up. He received no acute care after admission to merit reimbursement at that level.

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

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