Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting and Weight Loss
Treatment: Inpatient admission
The proposed inpatient admission was not medically necessary.

The patient is a female infant that was taken to the emergency department (ED) via EMS just after midnight with vomiting and weight loss. She had been seen by the pediatrician earlier in the day and was prescribed Prevacid and formula supplementation. She had multiple episodes of vomit described as yellow/green, no fevers, no diarrhea. She had an episode of vomiting in Triage that was described as green as well. 

The patient's vital signs included temperature 98.7, heart rate 147, and respiratory rate 44. Physical examination was significant for no distress, moist oral mucosa, regular heart rate and rhythm, clear lungs, non-tender abdomen with no masses or guarding or organomegaly, capillary refill three to four seconds, and non-focal neurologic exam. The differential diagnosis included urinary tract infection versus intussusception versus viral gastroenteritis. Pyloric stenosis was considered less likely due to age. Laboratory evaluation revealed mild metabolic acidosis (carbon dioxide [CO2] 21), negative urinalysis, unremarkable complete blood count (CBC) except for thrombocytosis (platelets 606K), and negative influenza and respiratory syncytial virus (RSV) screens. Chest x-ray was negative. Abdominal x-ray revealed mild sigmoid distention but was otherwise unremarkable. Abdominal ultrasound was negative, with no sign of intussusception. 

The patient was treated with two intravenous (IV) fluid boluses with improvement in capillary refill. Stool was guaiac positive twice. Attempt at breastfeeding was unsuccessful; she vomited the entire feeding. She was admitted to the pediatric floor for further management. Admission orders included maintenance IV fluids, nothing by mouth, and daily weights. She did well overnight with no vomiting, diarrhea, concerns. Urine output was appropriate, and the IV fluids had been discontinued at dinnertime. She remained afebrile, and her examination was unremarkable. She was given a diagnosis of presumptive acute gastroenteritis and deemed stable for discharge. 

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.

This baby presented to the ED with vomiting and poor oral intake. Her vomiting was bilious in character. She had no fevers or diarrhea. Her evaluation in the ED was essentially unremarkable with the exception of mildly prolonged capillary refill that was responsive to IV hydration, but she failed an oral challenge. She was overall hemodynamically stable with no radiographic evidence of obstruction and no clinical or laboratory evidence of sepsis. She did not require acute inpatient admission, but it was not unreasonable to observe her overnight at a lower level of care to document ability to tolerate fluids/feedings.