Appeal type: Medical necessity
Decision: Upheld

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

The patient was a previously healthy male, who was brought to the emergency department (ED) with a day of intermittent, inconsolable crying. He did not have a fever, vomiting, diarrhea, blood in the stool, or respiratory symptoms. On the morning of admission, he ate breakfast normally, but then refused to eat or drink, so the parents brought him to the ED. He was initially afebrile, but his temperature spiked to 103.4 degrees Fahrenheit while in the ED. During the period of observation in the ED, his abdominal ultrasound was normal, without sonographic evidence of intussusception. A complete blood count (CBC) was normal, erythrocyte sedimentation rate (ESR) normal. Bicarbonate was 18. Influenza, respiratory syncytial virus (RSV), and coronavirus disease (COVID) testing was negative. A urinalysis was negative with a specific gravity of 1.022. After his first intravenous (IV) fluid bolus he was described as "happy, active," but continued to refuse oral fluids. Before a second IV bolus he was described as remaining "playful," having eaten small amounts, but still "refused all liquids." After the second IV bolus the ED documented the patient was "well appearing but refusing to drink," and he was admitted to the pediatric inpatient unit. On arrival to the floor, he had normal capillary refill and a benign abdomen. He "drank 5 ounces (oz) of milk and ate cookies." The next day, he ate and drank well all day and did not have pain or fussiness. His respiratory viral panel came back positive for a coronavirus (not COVID-19). He was kept another night and then discharged. At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary.

By the time the patient was admitted to the pediatric floor from the ED, he was much improved clinically. During the hours of observation in the ED, he did not have episodes of belly pain that had been described by the parents. Because the historical description was consistent with intussusception, an abdominal ultrasound was done in the ED, which did not show intussusception or any other abnormality (this test is highly sensitive and specific for intussusception). The consistent comment from the ED physician is that the patient looks well, is playful, but does not want to drink. The physical exam did not support a diagnosis of significant dehydration. The laboratory values did not support anything more than the mildest dehydration--the urine was not very concentrated, and the bicarbonate was only mildly low. After receiving two fluid boluses, the patient was completely fluid repleted to whatever extent he was initially dry, and upon admission he was drinking and continued to drink. His appearance and lab results did not suggest a serious bacterial infection or sepsis syndrome, and he did not need (and did not receive) parenteral antibiotics. Per the Milliman Care Guidelines (5,6), he did not meet admission criteria under either guideline, because in the ED he had at most mild dehydration which was corrected, and on arrival to the floor he was taking by mouth (PO) liquids, and despite the fever, he did not have clinical or laboratory evidence of a serious bacterial infection.