Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting x 2 days.
Treatment: Inpatient admission.
The insurer denied coverage for Inpatient admission.
The denial is Upheld.

The patient is a child with a past medical history notable for sickle cell trait that presented to the Emergency Department (ED) for assessment and treatment of vomiting x 2 days with the last episode with blood streaks and coffee ground material, fever, recent nosebleed, decreased oral intake and fatigue. There was no associated cough, congestion, known weight loss, sick contacts, pain, dysuria, or melena. The patient had urinated twice during the day. The patient had no reported stools for the last 4 days. The patient's vital signs on arrival were notable for a Temperature of 102.6 Fahrenheit (F), heart rate (HR) of 160, blood pressure (BP) of 116/79, respiratory rate (RR) of 26, and room air oxygen saturation of 99% (percent). The patient's weight was 15 kilograms. Physical exam showed an alert, irritable child, crying in no apparent distress was ill appearing. The patient had documented both dry and moist mucus membranes, dried blood on their tongue, and normal capillary refill. Lungs were clear with normal effort. The cardiac exam was notable for tachycardia. The abdomen exam was soft. There was no associated pain, organomegaly, distension, rebound, guarding, or masses. Laboratory testing showed sodium 134, potassium 4.4, chloride 100, bicarbonate 22.5, blood urea nitrogen (BUN) 12, creatinine 0.38, glucose 94, white blood cell 4.7k without a left shift (neutrophils 54%), hemoglobin 11.5, platelet 224, albumin 4.7, bilirubin 0.3, aspartate aminotransferase (AST) 48, alanine transaminase (ALT) 19, alkaline phosphatase (AP) 287, international normalized ratio (INR) 1.2 and lactate 1.4. The respiratory pathogen panel was positive for Influenza B. The patient received one 300 cubic centimeter (cc) (20 cubic centimeters/kilogram [cc/kg]) normal saline bolus followed by Dextrose 5 normal saline at 50 cc/hour. In addition, the patient received oral Tylenol as well as oral Zofran and intravenous Pepcid. Repeat vital signs were notable for T 99.7 Fahrenheit, HR 126, BP 119/81, RR 26, and room air oxygen saturation of 98%. An electroencephalogram (EKG) was notable for HR 152. The decision to admit for observation, bowel rest, hydration, and a repeat complete blood count. The patient never had a stool heme checked. The patient's vomiting did not recur during the admission and was started on Tamiflu. No additional anti-emetics, Tylenol or Pepcid were administered. Repeat laboratories were notable for white blood cell count of 3.7k, hemoglobin 10.2, and platelets 217. The patient was started on a regular toddler diet that was tolerated well. No gastroenterology consult was requested. The patient was discharged home for outpatient follow-up with an HR 150.
 
To gauge the severity of their self-limited bleeding using heart rate alone was not accurate in this child. This child was merely observed for less than 24 hours after presentation with a repeat blood count to confirm what was seen clinically - namely, that the child's bleeding was not significant. There was no evidence of brisk bleeding or ongoing bleeding. The patient's laboratory abnormalities were not critical. The fever was never suspected to be from a bacterial source supported by the positive assessment for Influenza B and the normal white blood count. The fact that the patient had sickle cell trait was irrelevant and would not predispose to worsening severity of the illness. The patient received no acute care after admission to merit reimbursement at that 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 inpatient hospital admission is not substantiated.