Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Diarrhea and vomiting.
Treatment:  Inpatient admission.
The insurer denied the inpatient admission.  The denial is upheld. 

No, the inpatient admission was not medically necessary.

The patient is a female child with medical history significant for eczema and iron deficiency anemia and social history significant for living in a shelter that was taken to the ED via EMS with three-day history of diarrhea.  She had eaten a raw hot dog and had one episode of vomiting followed by diarrhea.  She was having approximately ten episodes of diarrhea daily, no blood, described as watery.  She was tolerating Pedialyte and milk but had decreased appetite.  She had fever only on the first day of illness. 

Vital signs included temperature 37.1, heart rate 146, and respiratory rate 32.  Examination was significant for no apparent distress, normal-appearing mouth, regular heart rate and rhythm, clear lungs, benign abdomen, and non-focal neurologic exam.  Laboratory evaluation revealed metabolic acidosis with carbon dioxide (CO2) 13. She refused an oral challenge.  She was treated with two normal saline boluses followed by maintenance fluids and admitted for further management of dehydration.  Admission orders included gastroenterology (GI) polymerase chain reaction (PCR), intravenous (IV) fluids, regular diet for age, and hold home iron.  Exam at the time of admission revealed a well-appearing child with moist mucous membranes, adequate capillary refill, and a 2/6 systolic murmur.  She remained on IV fluids until her stool output decreased and she was able to tolerate increased food/fluids by mouth.  Electrocardiogram was obtained as well as four-extremity blood pressures, and all were within normal limits.  GI PCR returned positive for rotavirus.  She was deemed stable for discharge to follow-up with the medical van.

Acute gastroenteritis is a major problem worldwide, representing one of the leading causes of morbidity and mortality in children.  There are an estimated 2.5 million deaths each year attributable to gastroenteritis in children under the age of five years.  Most cases are caused by viruses, are self-limited, and require supportive treatment.  According to the World Health Organization, oral rehydration therapy is the treatment of choice, particularly where diarrhea is the prominent feature and dehydration is mild to moderate.  Intravenous rehydration is indicated when oral rehydration fails or when output is excessive.  Output (vomiting, diarrhea) limits the success of oral rehydration, prompting use of anti-emetic medications.  According to current guidelines for evaluation and management of acute diarrheal illness, people with fevers or bloody diarrhea, as well as severe cramping or signs of sepsis, should undergo diagnostic studies to determine if antimicrobial agents are appropriate.  Additional testing, such as blood cultures, may also be indicated.

In this young child's case, she had copious water-loss stools up to ten times daily for three days.  By the time she presented to the ED, she was significantly dehydrated, with tachycardia on exam and metabolic acidosis on laboratory testing.  She was treated with two fluid boluses in the ED but refused to drink.  It was reasonable and appropriate to monitor her further in the hospital until she was able to drink sufficiently to sustain herself.  However, she was overall hemodynamically stable, with no signs of sepsis or severe dehydration.  She did not require acute inpatient admission and could have been safely managed at a lower level of care such as observation.