Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dehydration; Low Bicarbonate Level. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is a male infant born at term that presented to the emergency department with two-day history of vomiting. He had been seen the day prior as well. Following discharge from the emergency department on the prior day, the patient continued to have episodes of vomiting with each feeding as well as decreased urine output. Lab studies were obtained significant for pancytopenia with white blood cell (WBC) count 3600, hemoglobin 5.9, and platelets 72 thousand (K). The Hematologist/Oncologist on-call was consulted with recommendations to obtain type and cross, repeat lab studies to verify, and admit to the pediatric intensive care unit (PICU). The staff could not obtain the repeat lab studies. Bedside glucose was 90, and the patient was able to tolerate a feeding of formula. Rapid screening for COVID, respiratory syncytial virus (RSV), and influenza were all negative. The patient was treated with an intravenous fluid bolus and a dose of ceftriaxone before being admitted to the pediatric intensive care unit (PICU). At this point, there was concern for aplastic anemia. Admission orders included intravenous fluids at maintenance, ceftriaxone, antipyretics, transfusion administered over two hours, and repeat lab studies. 

Following admission, about three hours later, repeat lab studies were obtained. The results were significantly different with white blood cell (WBC) 8.4 thousand, hemoglobin 9.1, and platelets 439 thousand. Because of the vast improvement, no antibiotics or transfusion were indicated. Intravenous fluids were continued, but he was allowed formula ad lib (at will). He had no further episodes of vomiting. He was subsequently transferred to the pediatric floor for further management. By the time he arrived on the pediatric floor, the dehydration had resolved. The patient was deemed stable for discharge to continue oral rehydration with Pedialyte. 

The proposed inpatient hospital admission was not medically necessary. 

Acute inpatient admission was not medically necessary. 

This young child presented with tactile fevers, vomiting, decreased urine output, cough, and runny nose. Initial concerns were for bronchiolitis or other acute febrile illness. However, when the first laboratory studies returned, there was concern for pancytopenia because all three cell lines were affected and deficient. For this reason, he was admitted to the pediatric intensive care unit (PICU) for monitoring and transfusion. Repeat lab studies were obtained prior to transfusion, with normalization of all values. It is not clear why there was such a drastic change, 
but the repeat labs were considered reliable, so the transfusion and antibiotics were cancelled. He was transferred to the pediatric floor where he did well with no vomiting, tolerating his usual diet, playful and interactive. He was discharged a short time later. Given the initial grossly abnormal lab studies, the plan to repeat to confirm was appropriate. However, the emergency department staff was unable to obtain the necessary blood sample. Once the repeat lab studies were obtained in the pediatric intensive care unit (PICU) a couple hours later, there was no further concerns. In addition, the patient was able to tolerate his formula in the emergency department and was no longer vomiting. While it was reasonable to monitor in the hospital pending repeat lab studies and advancing diet, the patient was overall hemodynamically stable with no further vomiting and no other signs of critical illness. He did not require acute inpatient admission and could have been safely managed at a lower level of care.