Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute gastroenteritis

Treatment is an inpatient admission 

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

The patient has a past medical history notable for asthma, autistic spectrum disorder, and sickle cell trait that presented to the Emergency Department for assessment and management of a persistent non-bilious, non-bloody vomiting over the last 2-3 days, decreased oral intake, and watery non-bloody stools now resolved. There was no associated GI (gastrointestinal) bleeding, known weight loss or dysuria. The patient's vitals on arrival were notable for Heart Rate 110, Blood Pressure 100/57, Temperature 98 F (Fahrenheit), Respiratory Rate 24, and room air oxygen saturation of 98%. Admitting weight was 26 kilograms and height was 120 centimeters. 

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. 
 
A second reason given to justify the inpatient setting was significant dehydration. In regard to volume status in a second review of dehydration in children from UpToDate 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.

The documentation of this child's appearance and vitals would indicate mild 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 presentations the 2 days prior without intervention rather than the severity of his condition at the 3rd presentation. After admission he was merely observed with both intravenous and oral fluids, and safely discharged on oral fluids with outpatient follow-up. He actually received no acute care after admission to merit reimbursement at that level. Oral rehydration with or without solids could have been administered as an outpatient after demonstration of the ability to rehydrate enterally in the Emergency Department. 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 acute viral gastroenteritis and dehydration in children cited above.

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