Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dehydration

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.    

This is a young male patient who was transferred from another medical facility after being evaluated for complaints of abdominal discomfort that radiated to his right lower quadrant with associated nausea, vomiting, and diarrhea for a couple of days. While in the other medical facility he received two liters of intravenous (IV) normal saline with continued maintenance hydration. Upon arrival to the treating emergency department (ED) his vital signs were stable and his physical exam showed no apparent distress. He had a laboratory work up with normal findings. His urinalysis from the previous hospital was negative. An abdominal sonogram and abdominal x-ray were performed which revealed a normal compressible appendix and normal gas pattern. He continued to receive IV hydration. The patient had no further complaints of abdominal pain or vomiting and remained afebrile. The IV fluids were discontinued when he was able tolerate a diet. He remained medically stable and was discharged home with outpatient instructions.

This child appears to have a viral gastroenteritis with self-limited vomiting and minimal dehydration that responded adequately to intravenous repletion. His physical exam, laboratories and vitals were for the most part unremarkable. In accordance with a review of the approach to nausea and vomiting in children from Up To Date the reasons to admit such an individual would include signs of significant dehydration poorly responsive to intravenous hydration in the ED, hemodynamic instability, significant electrolyte imbalance, demonstrated oral hydration intolerance to oral challenge, poorly controlled pain with an oral pain medication regimen, concerning physical exam findings for a surgical process or findings consistent with significant blood loss or bowel obstruction. He did not meet any of these criteria to merit the inpatient setting. 

In regards to his volume status in a second review of dehydration in children from Up To Date the following elements summarize the assessment of the degree of dehydration: "Degree of dehydration - Fluid repletion guidelines for children with gastroenteritis by the American Academy of Pediatrics, Centers for Disease Control, and the World Health Organization are based upon the degree of volume depletion. As a result, it is important to be as accurate as possible when assessing the degree of dehydration. Severe hypovolemia requires rapid isotonic fluid resuscitation, although oral rehydration may be sufficient for mild to moderate hypovolemia. Mild dehydration (3 to 5 percent volume loss) - A history of fluid losses may be the sole finding, as clinical signs may be absent or minimal. Such patients may have a reduction in urine output, but this may not be appreciated. Moderate dehydration (6 to 9 percent volume loss) - Signs and symptoms are now apparent and can include the following: tachycardia, orthostatic falls in blood pressure, especially with orthostatic changes, decreased skin turgor, dry mucous membranes, irritability, decreased peripheral perfusion with a delay in capillary refill between two and three seconds, and deep respirations with or without an increase in respiratory rate..." 

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

The carrier's denial of coverage for the inpatient hospital services at the acute level of care is upheld. The medical necessity is not substantiated.