Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Weakness, Diarrhea, Vomiting

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

Patient presented with a benign past medical history to the Emergency Department (ED) of Mount Sinai Nassau Community Hospital complaining of non-bloody, non-bilious vomiting for 1-2 days, diarrhea for 2 days, constipation for 2 days, decreased oral intake and decreased dark urine output. There was no associated fever, cough, wheezing, shortness of breath, weight loss, or dysuria. The patient's vitals were notable for pulse 124, temperature 98.5 Fahrenheit (F), respiratory rate (RR) 20, blood pressure (BP) 99/71 and room air oxygen saturation of 98% (percent). Physical exam showed a weak, non-ill appearing female in no apparent distress. The patient had moist mucus membranes, dry skin and normal skin turgor. Lungs were clear with normal effort. Cardiac exam was unremarkable. Abdomen exam was soft and flat. There was no associated pain, organomegaly, distension, rebound, guarding or masses. There was no rectal exam reported. Admitting laboratories were notable for sodium 137, potassium 4.5, bicarbonate 12, blood urea nitrogen (BUN) 14, creatinine 0.42, glucose 57, white blood count (WBC) 5.4, hemoglobin (Hgb) 12.3, platelets 241, lipase 10 and normal hepatic profile for age. Respiratory viral panel was negative for influenza A/B, respiratory syncytial virus (RSV) and COVID. Urinalysis was notable for specific gravity 1.034, pH (potential of hydrogen) 5.5 and dip positive for large ketones. The patient received two 320 milliliter (ml) boluses of normal saline followed by Dextrose 5% (D5) normal saline at 52 ml/hour later adjusted to 66 ml/hour. In addition, the patient was given Dextrose 50% (D50) 12.5 grams (gm) intravenous (IV) push. Imaging included an unremarkable abdominal x-ray. While in the ED the patient tolerated 10% of a regular meal and had drunk 12 bottle of Gatorade. The decision to admit the patient to the inpatient unit for dehydration and metabolic acidosis in the setting of acute gastroenteritis occurred. The patient's admitting weight was 16.2 kilograms (kg) and the patient's height was 106.6 centimeters (cm). Once admitted the patient received intravenous fluid with oral diet as tolerated. No diarrhea or vomiting occurred throughout the admission. The patient remained afebrile. No pain medications or anti-emetics were required. Repeat labs were notable for sodium 141, potassium 3.2, bicarbonate 23, BUN (Blood urea nitrogen) 4, creatinine 0.35, and glucose 99. The patient was discharged home with a heart rate of 107.
 
The documentation of this child's appearance (moist mucus membranes and normal skin turgor) and vitals/weight would indicate mild dehydration on presentation that resolved prior to the decision to admit. The fluid resuscitation delivered in the Emergency Department had not even been completed before the child was prematurely admitted to the inpatient setting. Intravenous dextrose and fluids to clear ketones would have been enough to permit adequate oral rehydration as per standard of care. The patient appeared to be admitted for observation and supplemental intravenous fluids secondary to metabolic acidosis that was clearly from ketosis and not lactic acidosis from poor tissue perfusion. This patient actually never received any acute care after admission to the inpatient setting to merit reimbursement at this level. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is not substantiated.