Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Vomiting.
Treatment:  Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld

The patient was brought to the hospital by his mother for vomiting for 1 day.  He began vomiting on the morning of presentation.  He tried to drink broth; however, he vomited immediately after.  His mother took him to the pediatrician, and he was sent home after he was able to tolerate Pedialyte in the office.  The mother reported that a throat swab was done in the office and was negative.  The patient proceeded to vomit in the car on his way home from the pediatrician's office.  He had a total of 4 episodes of vomiting.  There was no fever, chills, cough, congestion, urinary symptoms or diarrhea.  The patient had pizza and Caesar salad at a restaurant the night prior to presentation.  No one else who ate at the restaurant had similar symptoms.  He urinated twice on the day of presentation.  In the emergency room (ER) he was tachycardic with a heart rate (HR) in the 150s.  He was normotensive and afebrile.  HR 150, respiratory rate (RR) 28, Temperature 97.5 degrees Fahrenheit, blood pressure (BP) 109/65.  He had another episode of vomiting.  A complete blood count (CBC) was unremarkable, he had a normal white blood cell count (WBC) with neutrophilic predominance.  A comprehensive metabolic panel (CMP) showed a decreased carbon dioxide (CO2) of 16, glucose of 66, and elevated blood urea nitrogen (BUN) of 26.  He received a normal saline (NS) bolus times (x) 2 and Zofran x 1 in the ER.  He was admitted to the pediatric floor and kept nothing by mouth (NPO) overnight and on intravenous fluids (IVF).  The following morning he was advanced to a clear liquid and then a regular diet, which he tolerated without difficulty.  He did not have any emesis after leaving the ER.  He was then cleared for discharge home and instructed to follow up with his primary medical doctor (PMD) in 2-3 days as an outpatient.  At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary for this patient.  This patient presented with a one day history of vomiting.  His initial vital signs revealed a HR of 150, but no physical signs of dehydration were reported.  After ER management of IV Zofran x 1 and NS bolus x 2, the patient responded with a HR down to 103 approximately 30 minutes before the admit order was placed.  The nursing notes reported that the patient had an episode of emesis during the ER physician's initial assessment.  There was no mention of a failed by mouth (PO) trial in the ER.  There was no mention of PO intolerance.  The patient did not have any further emesis after admission to the hospital.  He was discharged in less than 24 hours.  This patient did not meet criteria for inpatient hospital admission.  He was never described to be clinically dehydrated.  His illness was not severe to require increased intensity of services that would qualify for inpatient admission.  No highly technical or skilled care was ordered upon admission.  Inpatient care was not needed.  His clinical presentation as well as his clinical course were both of low acuity and could be well managed at a lower level of care.