Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Gastroenteritis.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient presented to the hospital for acute onset vomiting and decreased oral intake. On presentation, her vital signs were normal. Her evaluation was concerning for dehydration secondary to acute gastroenteritis. She was started on intravenous fluids and anti-emetics. Her diet was gradually advanced until tolerated. She was discharged home in a stable condition. At issue is the medical necessity of an inpatient stay.

This patient presented to the emergency room with 3 days of vomiting and developed signs of severe dehydration. Her oral intake was low and she was not able to maintain hydration orally. Her laboratory studies showed acidosis with a low bicarbonate level.
The admission was medically necessary to correct the dehydration and acidosis, improve the patient's overall condition and prevent complications. Outpatient management of this patient was not appropriate because oral hydration was not possible. Therefore, the patient had a severe case of dehydration and required admission to stabilize her condition and treat her appropriately. The admission was medically necessary and consistent with the standard of care.
Most gastroenteritis cases do not require inpatient care. However, a small percent of patients develop severe dehydration and require intravenous rehydration and hospital care.
Per Banyai, K., et al. (2018) "For treatment of dehydration caused by gastroenteritis viruses, the administration of reduced-osmolality oral-rehydration solutions (5060 millimoles per liter (mmol/L) sodium) is the first line of therapy. Profuse vomiting, worsening dehydration with altered consciousness, or severe acidosis, hypovolemic shock, abdominal distension, and ileus are indications for intravenous rehydration".
Per Hartman Sl. et al. (2019), "Acute gastroenteritis is defined as a diarrheal disease of rapid onset, with or without nausea, vomiting, fever, or abdominal pain. In the United States, acute gastroenteritis accounts for 1.5 million office visits, 200,000 hospitalizations, and 300 deaths in children each year. Evaluation of a child with acute gastroenteritis should include a recent history of fluid intake and output... Hospitalization and intravenous fluids are recommended for children who do not respond to oral rehydration therapy plus an antiemetic and patients with severe dehydration (i.e., signs of shock or more than 10 percent (%) dehydration). Handwashing, breastfeeding, and rotavirus vaccination reduce the incidence of acute gastroenteritis in young children."
Per Vega, R. M. and Avva, U. (2019), "Dehydration is a major cause of morbidity and mortality in infants and young children worldwide. Each year approximately 760,000 children of diarrheal disease worldwide. Most cases of dehydration in children are the consequence of acute gastroenteritis... Metabolic acidosis is seen in infants and children with dehydration, the pathophysiology of which is multifactorial. 1. excess bicarbonate loss in the diarrhea stool or in the Urine is certain types of renal tubular acidosis. Priorities in the management of dehydration include early recognition of symptoms, identifying the degree of dehydration, stabilization, and rehydration strategies." Therefore, the admission was consistent with generally accepted practices and was medically necessary.