Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute gastroenteritis
Treatment: Inpatient admission 
The insurer denied coverage for the inpatient admission.
The denial is upheld.

This patient is a toddler that was transferred to the Emergency Department (ED) for assessment and management of fever, persistent watery non-bloody stools over the last 7-8 days, decreased oral intake, decreased urine output and metabolic acidosis. The patient's vitals on arrival were notable for heart rate (HR) 120, blood pressure (BP) 108/65, Temperature 98 Fahrenheit, respiratory rate (RR) 24 and room air oxygen saturation of 100%. Admitting weight was 11.5 kilograms and height was 86 centimeters. Physical exam showed an active male in no apparent distress. He was awake and alert crying with tears. He had moist mucus membranes with normal capillary refill (<2 seconds). Lungs were clear with normal effort. Cardiac exam was unremarkable. Abdomen exam was soft. There was no associated pain, organomegaly, distension, rebound, guarding or masses. There was no rectal exam reported. Admitting laboratories were notable for a point of service glucose 127. Nasal viral washings on were negative for respiratory syncytial virus (RSV), COVID (coronavirus disease) and influenza. No additional imaging was performed. The decision was made to admit him for observation and hydration for acute gastroenteritis and dehydration. Nursing notes stated, "feels much better, no nausea or vomiting, awaiting bed." He was transferred to a floor bed with a HR (heart rate) of 105 and weight was 11.8 kilograms. His exam was normal, and he was noted to eating and drinking well, but had several loose stools. His IV (intravenous) fluids were decreased to 23.3cc (cubic centimeters)/hour. He continued to tolerate oral intake and hydration and IV fluids were stopped. Repeat laboratories were notable for sodium 138, potassium 4.3, chloride 106, bicarbonate 20, blood urea nitrogen (BUN) 4.3, creatinine 0.2, glucose 81, white blood cell 11 without a left shift (neutrophils 33%), hemoglobin 10.9 and platelet 275. Stool gastrointestinal (GI) polymerase chain reaction (PCR) was positive for astrovirus and enteropathogenic E. (Escherichia) coli. No antibiotics or antipyretics were administered. 

The documentation of this child's appearance and vitals at presentation would indicate mild-moderate dehydration that resolved with IV resuscitation within hours of his arrival and prior to transfer for admission. 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 the fact that he was transferred in from another center rather than the severity of his condition. He was never at risk of life-threatening hypovolemia as stated in the appeal. After admission he was observed with both modest IV 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 ED. 

In regard to the acute inpatient admission the determination by the carrier that the admission was not medically necessary was correctly applied, objective, clinically 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 reviews from UpToDate summarizing the approach to acute viral gastroenteritis and dehydration in children.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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