Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dehydration
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male child that presented to the ED (emergency department)  with three-day history of tactile fevers and diarrhea, and one-day history of vomiting. The family had been traveling, where the baby was given well water, returning a week prior to presentation. Initially the mother was treating with Tylenol, but because he started vomiting and appeared more tired, she brought him to the ED for evaluation. 

The patient's vital signs included temperature 99.7, heart rate 152, respiratory rate 20, and 98% saturation in room air. Physical examination revealed a tired-appearing infant with moderate dehydration, irritable but consolable, with dry oral mucosa, cracked lips, palpable pulses, diffusely tender abdomen with no guarding, increased bowel sounds, pallor, and three second capillary refill. Laboratory studies were significant for normal WBC (white blood cell) count with slight left shift, mild hyponatremia and hyperkalemia (134 and 5.5, respectively), significant metabolic acidosis (CO2 [carbon dioxide] 14), elevated BUN (blood urea nitrogen) (20), mildly elevated AST (aspartate aminotransferase) (63), normal inflammatory markers, and hypoglycemia (glucose 57). Venous blood gas was consistent with metabolic acidosis. Rapid influenza and RSV (respiratory syncytial virus) tests were negative. 

The patient was diagnosed with moderate dehydration secondary to vomiting and diarrhea, and he was treated with two normal saline boluses followed by 1.5x maintenance IV (intravenous) fluids and Zofran. He failed an oral challenge twice and so was admitted to the pediatric floor for further management. Admission orders included 1.5x maintenance IV fluids, regular diet for age as tolerated, and follow-up blood and stool cultures. 

The patient did well overnight so that IV fluids were stopped in the morning. He had no further vomiting, remained afebrile, and demonstrated good oral intake. He was subsequently deemed stable for discharge. Cultures were ultimately negative. 

No, the Inpatient admission was not medically necessary.

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. Vomiting limits the success of oral rehydration, prompting use of anti-emetic medications. Hospitalization may be necessary for those that do not respond to oral hydration and anti-emetic treatment, as well as those with severe dehydration.

This male child, an infant at the time, presented to the ED (emergency department) with several-day history of diarrhea and new-onset vomiting with refusal to drink. He was found to be hypoglycemic with laboratory evidence of dehydration (metabolic acidosis noted). Despite fluid resuscitation in the ED as well as treatment with Zofran, he refused to drink, prompting admission for further management. While it was reasonable to monitor him in the hospital for improvement in drinking and resolution of dehydration, he was overall hemodynamically stable with no evidence of impending shock, no respiratory compromise, and no indication of intra-abdominal pathology (e.g., obstruction). He did not require acute inpatient admission, and he could have been safely managed in the hospital at a lower level of care such as observation.