Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vomiting; diarrhea
Issue under review: Inpatient admission

Determination:
The health plan denied Inpatient admission. The health plan's denial is overturned.

The patient is a male toddler with unremarkable medical history. He presented to the ED with two-day history of vomiting (seven episodes) and diarrhea (twelve episodes), decreased intake, decreased urine output, and cough. He had a similar episode two weeks prior, which had resolved after using Pedialyte. There was no history of daycare attendance, ill contact, or fevers. 

The patient's vital signs included temperature 37.6, heart rate 148, respiratory rate 24, and 98% oxygen saturation in room air. Examination was significant for no acute distress, appearing "dry," crying with exam, non-toxic appearance, erythematous right tympanic membrane with impacted cerumen, moist mucous membranes, posterior oropharyngeal erythema, normal cardiac exam, clear lungs, normal bowel sounds, benign abdominal exam, brisk capillary refill, and non-focal neurologic exam. 

The patient's laboratory evaluation was significant for leukocytosis with WBC (white blood cell) count 15.6K and 61% neutrophils, metabolic acidosis with CO2 (carbon dioxide) 19, elevated BUN (blood urea nitrogen)/creatinine ratio, and elevated alkaline phosphatase of 249. He was diagnosed with acute gastroenteritis with dehydration and food intolerance. He had no vomiting in the ED, but he refused an oral challenge. He was given a normal saline bolus, and plans were made to admit to the pediatric ward for management of moderate dehydration. 

The patient's admission orders included clear liquid diet, maintenance IV fluids, and obtain stool studies. He had no further vomiting, but he did have three diarrhea stools overnight. He continued to have a congested moist cough as well. Stool studies returned negative. His diet was advanced to regular for age and nebulized saline was added every three hours. There was consideration for discharge, but he was unable to tolerate an oral diet, and he lost his IV line. 

The following day, the patient still presented with mild dehydration and food intolerance. His IV was replaced and he was given a normal saline bolus followed by half-maintenance IV fluids. Again, there was consideration for discharge later in the day. His oral intake remained inadequate until the following day, when he was deemed stable for discharge to home.

This young child presented to the ED with two-day history of multiple episodes of vomiting and profuse water-loss diarrhea. He had no further vomiting after presentation, but he continued to have frequent diarrhea, including three episodes in the ED. Even though he was not vomiting, he refused an oral challenge, necessitating treatment with IV fluids. He was admitted because he had ongoing diarrhea and was not drinking. Even after admission, with continued fluid losses from diarrhea, and he was not drinking. Each day he was evaluated for possibility of discharge, but because he was not drinking, he was not safe to discharge home. He even required replacement of his IV so that he could receive a fluid bolus on the fourth hospital day. It was not until the fifth hospital day that his diarrhea had improved sufficiently and he was taking adequate fluids by mouth to keep up with his metabolic needs. This level of care is most consistent with acute inpatient management. He could not have been safely managed at a lower level of care.