Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented with vomiting and a fever, and a maximum temperature (Tmax) of 100.6 degrees Fahrenheit for 4 days. His mother stated that he also had a headache and ear pain. There were no sick contacts at home. The patient's mother endorsed a decreased appetite and abdominal pain as well. The patient had only been able to tolerate water and juice. He has a past medical history (PMHx) of recurrent nausea and vomiting episodes once a month for the past 6 months. His mother also endorsed hard stools daily. The exam in the emergency room (ER) was unremarkable except for mild tenderness to the periumbilical region. The laboratory evaluation in the ER revealed an elevated white blood cell count (WBC) at 24.8 and a C-reactive protein (CRP) of 8.97 milligrams per deciliter (mg/dL). The rapid respiratory viral panel returned with human rhinovirus/enterovirus being positive. An abdominal ultrasound (US) was completed but could not exclude appendicitis. An abdominal computed tomography (CT) scan was then completed which was limited by motion but no acute appendicitis was suspected, probable mildly prominent mesenteric lymph nodes. Given the patient's continued complaints of abdominal pain, the ER physician decided to admit him for dehydration and abdominal pain.
He was started on intravenous fluids (IVF) and Zofran as needed (PRN) for nausea. A clear liquid diet was ordered and was to advance as tolerated. Amoxicillin was ordered for right acute otitis media. His repeat labs the day after admission revealed an increase in the WBC to 30.5 and CRP to 16 respectively. He had a temperature of 104.5 degrees Fahrenheit that night as well as 2 episodes of diarrhea. There was a concern for sepsis due to the lab results, so a blood culture was drawn. The decision was made not to start broad spectrum antibiotics given no evidence of a serious bacterial infection on exam or imaging. The following day the patient's labs downtrended to a WBC of 16 and a CRP of 13. He was given Tylenol PRN for fever. He was given Ranitidine and Maalox for possible gastritis and Miralax daily for constipation. Prior to discharge, he was afebrile, hemodynamically stable and tolerating by mouth (PO). He was discharged with Amoxicillin and instructions to follow up with his primary medical doctor (PMD).
The health plan 's determination is upheld.
 The admitting diagnoses per the attending provider's note were dehydration and abdominal pain. The patient did not meet inpatient admission criteria for either of these diagnoses. He was found to have right otitis media as well as Human Rhinovirus/Enterovirus which would account for the symptoms hewas experiencing. The patient did not have any findings as a result of these two diagnoses that would warrant an inpatient level of care. Although he had elevated inflammatory markers, he did not have any signs of sepsis or hemodynamic instability. There were no signs of a surgical abdomen and no radiological studies to support this diagnosis. At the outset, the completed CT scan of the abdomen revealed the patient most likely had mesenteric adenitis. There was no mention of a failed PO trial in the pediatric emergency room. There were no physical findings or laboratory values to support significant dehydration. Oral antibiotics for otitis media as well as oral rehydration, as there was no mention of PO intolerance, would be acceptable care for this patient. This could have been provided at a lower level of care.