Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever, vomiting
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient had a right ectopic kidney and bilateral vesicoureteral reflux (VUR) grade 2 who presented with 3 days of fevers and reduced by mouth (PO) intake with a concern for dehydration in the setting of febrile illness. 2 days prior to presentation, the patient developed a fever up to 104 degrees Fahrenheit. Also she had a reduced appetite and several episodes of nonbloody, nonbilious (NBNB) emesis. Since then, the fevers were continuing intermittently and her eating and drinking steadily declined.
On the day of presentation she continued with a fever and had only 1 wet diaper. She was seen by her primary medical doctor (PMD) on the day of presentation and the office notes report that the child was refusing by mouth (PO) fluids and upon bladder catheterization, no urine was noted in her bladder. This prompted the PMD to send her directly to the emergency room (ER). Of note, she takes Keflex for urinary tract infection (UTI) prophylaxis, she had been unable to tolerate this the 3 days prior to presentation.
In the emergency room (ER), the patient was noted to be ill appearing and tachycardic. The ER nurse reported dry mucous membranes and tachycardia. The triage heart rate (HR) was 151. Initial lab results were notable for mild leukopenia and the basic metabolic panel (BMP) was suggestive of mild anion gap metabolic acidosis. She received a bolus times (x) 1 and Zofran, however, she refused to eat or drink so she was admitted to the pediatric floor for dehydration in the setting of likely viral illness.
The admission exam documented a temperature of 97.1 degrees, heart rate (HR) 129-151, respiratory rate (RR) 26-30, and oxygen saturation (O2 sat) 97-100% on room air (RA). The patient was described as ill appearing with capillary refill 2-3 seconds. Lab results revealed a white blood cell count (WBC) of 4.6, carbon dioxide (CO2) 16 and urine specific gravity (SG) greater than (>) 1030 with 1 plus (+) ketones. The patient was given 2x normal saline (NS) bolus and maintenance intravenous fluids (MIVF) overnight. After discontinuing fluids, she was able to tolerate PO sufficiently and was felt to be safe for discharge home with close follow up with the primary care physician (PCP). Her mother reported fussiness but baseline energy level. She was initially on IV Cefazolin for VUR prophylaxis instead of her home PO regimen but restarted on home Keflex once able to tolerate PO. In discussion with urology team, she will continue to follow up with them outpatient for her VUR/need for prophylactic antibiotics.
The issue for review is the medical necessity of the inpatient stay.

Inpatient admission was medically necessary for this patient.

This patient presented with tachycardia, an ill appearance, dry mucous membranes, capillary refill 2-3 seconds, CO2 of 16 on BMP and urinalysis with SG >1.030. Her signs and symptoms were suggestive of significant dehydration that would require an inpatient level of care for close monitoring of her intake and output (I and O) and intravenous fluid (IVF) resuscitation given her PO refusal. This patient presented not only with physical findings but also laboratory evidence of significant dehydration associated with low CO2 levels, indicating metabolic acidosis, as well as concentrated urine. She met criteria for inpatient admission due to her inability to maintain oral hydration as a result of her PO refusal. 
This patient presented not only with physical findings but also laboratory evidence of significant dehydration associated with low CO2 levels and concentrated urine. Based on current criteria, this patient was a candidate for admission due to her inability to maintain oral hydration (eg, needs IV fluid support) that persisted after ER management. Per the literature current criteria for admission include:
1)	caregivers cannot provide adequate care at home;
2)	Substantial difficulties exist in administrating oral rehydration therapy (ORT), including intractable vomiting, oral rehydration solution (ORS) refusal, or inadequate ORS intake;
3)	Concern exists for other possible illnesses complicating the clinical course; ORS treatment fails, including worsening diarrhea or dehydration despite adequate volumes;
4)	Severe dehydration (>9% of body weight) exists; Social or logistical concerns exist that might prevent return evaluation, if necessary
5)	Factors as young age, unusual irritability or drowsiness, progressive course of symptoms, or uncertainty of diagnosis exist that might indicate a need for close observation.
Due to her inadequate oral intake as well as her significant metabolic acidosis, inpatient hospital stay was medically necessary.