Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Presumed moderate dehydration, rule out viral illness. 
Treatment: Inpatient admission. 

The insurer denied coverage for the inpatient admission. 

The denial is upheld. 

This patient is a female child with a past medical history notable for global developmental delay, macrocephaly, and chronic constipation. The patient presented to the Emergency Department (ED) for assessment and management of 3 days of loose stools (resolved 2 days prior to admission), lethargy, decreased oral intake and irritability. The patient was voiding with 2 wet diapers per day and tolerating Pedialyte by mouth. The patient's vital signs were notable for: temperature 99 degrees Fahrenheit, heart rate 130, respiratory rate 26, blood pressure 73/30, and oxygen saturation 100% on room air. The patient's physical exam was notable for a "slightly lethargic", alert child, in no apparent distress with moist mucus membranes. The patient's oral pharynx was erythematous without exudate and her tonsils appeared hypertrophied. The patient's lungs were clear and she had a normal cardiac exam. The patient's abdominal exam showed normal bowel sounds without tenderness to palpation, guarding, distention, rebound, organomegaly or masses. The patient's lab work was notable for sodium 138, potassium hemolyzed, serum bicarbonate 8, blood urea nitrogen (BUN) 14, creatinine 0.5, glucose 37, white blood cell (WBC) count 8.8 (60% neutrophils and no bands), hemoglobin 14.2 and platelets 249. The patient's nasopharyngeal polymerase chain reaction (PCR) test was positive for parainfluenza. The patient was given a bolus of normal saline followed by dextrose (D5) normal saline with potassium. The patient was offered oral fluid but refused. A glycerin suppository was given in the ED. The decision was made to admit the patient for presumed moderate dehydration, rule out viral illness. 
   
Based on the review of the medical record, this patient appeared to have viral gastroenteritis with self-limited diarrhea that resolved prior to presentation and mild dehydration responding to modest intravenous (IV) fluids prior to admission. The patient's physical exam findings and laboratories excluded worrisome conditions and her lethargy improved once given fluids and dextrose. According to a review of the approach to acute viral gastroenteritis in children in resource-rich countries from UpToDate, the reasons to admit such an individual to the acute care setting would include signs of significant dehydration poorly responsive to IV hydration in the ED, 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. However in this case, this patient met none of these criteria. 

As per review of the UpToDate literature on dehydration in children, this patient was mildly dehydrated on presentation that improved/resolved with a single bolus of normal saline as resuscitation. The patient's refusal to drink prior to resuscitation does not constitute a failed oral challenge, as this patient never vomited with oral trial. Thus, this patient's management in the ED was part of her outpatient management that did not fail. As could be predicted, the patient required no acute care after admission and tolerated fluids and diet shortly after admission. 

The determination by the carrier in regards to the denial of acute care admission was correctly applied, objective, clinical valid, compatible with established principles of health care and flexible enough to permit justified variation. The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated. The insurer's denial should be upheld.