Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute gastroenteritis
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld
Patient was a toddler with medical history of eczema that presented to the emergency department for fever 100.4 Fahrenheit (F), non-bloody, non-bilious vomiting x1 day, non-bloody watery stools over the last 3 days, decreased oral intake, decreased urine output and fatigue. There was no associated cough, congestion, gastrointestinal (GI) bleeding, known weight loss, sick contacts, pain or dysuria. The patient was still making wet diapers. The patient's vital signs on arrival were: temperature 99.7 F, heart rate 138, respiratory rate 24 on room air oxygen saturation of 98%. The patient's weight was 15.9 kilograms (kg). Laboratory tests were: Sodium 140, potassium 4.4, chloride 103, bicarbonate 16, blood urea nitrogen (BUN) 15, creatinine 0.36, glucose 61, white blood cell (WBC) 8.36k with a left shift (73.7% neutrophils, no bands), hemoglobin 12.8, and platelet 242, Glucose was 46. The patient received Dextrose 10% Water @ 5 cc/kg (cubic centimeters/kilogram) which increased glucose to 196. The patient received one 20 cc/kg 318cc normal saline bolus and Pedialyte orally. A non-clean catch urinalysis showed specific gravity >1.030, potential of hydrogen (pH) 5.5, dip + small blood, ketones 80, nitrate/leukocyte esterase neg, WBC 11-20, RBC 21-50, hyaline casts 2-5 and squamous epithelial cells 11-20. At the time of the urine collection, the patient had a large watery stool so a second 318 cc normal saline bolus was given followed by Dextrose 5% normal saline @ 50cc/hour. In addition, Ceftriaxone was given for a possible urinary tract infection. The patient was transferred for admission to another facility for dehydration and acute gastroenteritis. Respiratory pathogen panel was negative for influenza A/B and Covid-19. A repeat urinalysis showed specific gravity 1.018, pH 5.5, dip + moderate blood, ketones 40, nitrate/leukocyte esterase neg, WBC 0-4, and RBC 21-50. Vital signs were stable. The patient's admitting physical exam showed a happy child playing in mom's arms in no apparent distress. The patient had moist mucus membranes with normal capillary refill (<2 seconds). The patient cried with tears, the lungs were clear with normal effort, the cardiac exam was unremarkable. Abdomen exam was soft. There was no associated pain, organomegaly, distension, rebound, guarding or masses. Intravenous (IV) fluids were continued @ 52cc/hour and the patient was permitted a regular diet that was tolerated. Vomiting and diarrhea did not recur during the admission. The intravenous fluids were stopped and a second dose of Ceftriaxone was given. The patient continued to tolerate oral intake and hydration. No repeat laboratories were performed. No anti-nausea or antipyretics were administered. The patient was discharged home for outpatient follow-up with a heart rate 125.
 
This child appears to have a viral gastroenteritis (loose stools, self-limited vomiting) and mild dehydration that resolved by the time of admission to the inpatient setting. The patient was able to tolerate oral rehydration but the amount appeared inadequate compared to his reported losses. 
The documentation of this child's appearance and vitals at presentation would indicate mild -moderate dehydration that resolved with intravenous resuscitation prior to his arrival His laboratory abnormalities were not critical and would be expected to correct with fluid resuscitation followed by oral rehydration therapy. The patient's weight change after 2 boluses and 1.5 maintenance fluids was only 0.1 kilograms. The patient appeared to be admitted more for the convenience of the treating team rather than the severity of the overall condition. The patient demonstrated no symptoms of a urinary treat infection yet received 2 doses of antibiotics despite a reassuring repeat urinalysis.