Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pancolitis and mesenteric adenitis 

Treatment: Inpatient admission

The insurer has denied Inpatient admission. The denial was upheld.

The patient is a female child with no significant past medical history who presented to the Emergency Room for left lower quadrant abdominal pain and vaginal bleeding.  Upon arrival, the patient had 5/10 acute abdominal pain and a temperature of 39.1 Celsius.  The patient was given two liters of normal saline and was still found to have ketonuria.  A Computerized Tomography (CT) of the pelvis revealed pancolitis and mesenteric adenitis.  The patient was admitted for pancolitis and kept nothing by mouth (NPO).  A Gastroenterology consultation was done.  They recommended obtaining stool cultures and testing for clostridium difficile.  Intravenous pain medications, antibiotics, antiemetics, and fluid were prescribed.  Input and output was strictly monitored.  The patient's pain improved after treatment and her diet was advanced as tolerated.  She was discharged after a period of stability. The insurer has denied coverage for the inpatient admission as not medically necessary based on InterQual Criteria-Medical.

Lab work revealed: a complete blood cell (CBC) count with a white blood cell (WBC) count of 8.5, a hemoglobin of 11.9, an international normalized ratio (INR) of 1.2, a sodium of 130 (low), a potassium of 2.9 (low), and a carbon dioxide of 20.  A hepatic function panel was normal.  A human chorionic gonadotropin (HCG) was negative. A urinalysis revealed protein, WBCs, and blood. A Gastroenterology (GI) consultation was obtained who recommended an ultrasound of the abdomen (not done due to CT having been done), fecal calprotectin, C difficile, and to hold antibiotics pending stool studies. The patient received Ketorolac, Reglan and intravenous (IV) fluids. Fecal occult blood was negative. An erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were elevated. By morning, the patient reported that her abdominal pain had decreased to 4/10.  She had six episodes of diarrhea since being in the ED.  It was felt that she would be able to tolerate liquids. She was subsequently started on clear liquids. 
 
Documentation states that the patient's pain improved with decreased diarrheal frequency. Her abdomen was nontender on examination.  Her heart rate was 82, her blood pressure was 95/60, and her temperature was 98.8.  The patient was deemed ready for discharge. Based on the heart rate, this patient likely presented with mild to moderate dehydration. Initial laboratory studies showed mild hyponatremia, hypokalemia, and acidosis.

According to 2014 guidelines for the management of acute gastroenteritis in children, indications of hospitalization for acute gastroenteritis in this population include shock, severe dehydration, neurological abnormalities (lethargy, seizures, etc), intractable or bilious vomiting, failure of oral rehydration, and/or suspected surgical condition. While it was reasonable to hydrate and provide pain control for the patient, she showed sufficient improvement to take oral fluids.  She showed no vomiting.  There was no record of the patient requiring pain control that could not have been administered orally.  She was continuing to have loose stools, though this is not an indication for hospitalization, nor is colitis and enteritis.  

The admission of this patient was not medically necessary.  She could have been observed and when, as noted above, she was able to take oral fluid she could have been sent home.  The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.  

Based on the above, the medical necessity for the inpatient hospital services at the inpatient level of care not substantiated. The insurer's denial is upheld.