Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

 
This is a patient with a past medical history notable for polydactyly that presented to the Emergency Room (ER) for the 3rd time in one week complaining of recurrent non-bloody, non-bilious vomiting x (times) 3 episodes and decreased oral intake. The child was first seen 4 days prior with complaints of constipation and one episode of diarrhea with low grade fever. The patient was seen for the second time with vomiting x 4 episodes treated with Zofran and discharged. There was no associated cough, wheezing, shortness of breath, weight loss, decreased urine output or dysuria. The patient's vitals were notable for pulse 139, Temp 37.2 Celsius, respirations 36 and room air oxygen saturation of 100% (percent). Physical exam showed a tired, non-ill appearing patient in no apparent distress. The patient had moist mucus membranes and cap refill < (less than) 2 seconds. Admitting laboratories were notable for sodium 136, bicarbonate 20, blood urea nitrogen (BUN) 17, creatinine 0.5, and glucose 104. No complete blood count, amylase or lipase were assessed. Respiratory viral panel was negative for influenza A/B, respiratory syncytial virus (RSV) and COVID. No urinalysis was submitted for review. 

The insurer is denying the acute inpatient admission as not meeting medical necessity criteria for acute inpatient admission by lack of serious findings in the vitals, labs, physical exam and history to meet Millman Care Guideline 26th Edition standards for Vomiting, Pediatric for the acute inpatient setting. 
 
This child appears to have norovirus associated gastroenteritis with self-limited vomiting x 24-36 hours followed by diarrhea and no dehydration. Although intake was overall decreased, the was never significantly dehydrated and was admitted prior to Zofran and fluid repletion was administered. In accordance with a review of the approach to acute viral gastroenteritis in resource rich countries in infants and children from UpToDate the reasons to admit such an individual would include signs of significant dehydration poorly responsive to intravenous hydration in the Emergency Room, significant weight loss, profound lethargy, hemodynamic instability, significant electrolyte imbalance, demonstrated oral hydration intolerance to oral challenge, poorly controlled pain with an oral pain medication regimen, concerning physical exam findings for a surgical process or findings consistent with significant blood loss or bowel obstruction. 
 
A second reason given to justify the inpatient setting was significant dehydration. In most cases, however, a previous recent weight is not available. As a result, a number of findings on physical examination coupled with the pertinent clinical history are used to help assess the severity of hypovolemia. These findings include the child's pulse, respiratory rate, blood pressure, skin turgor, peripheral perfusion (delayed capillary refill) and systemic signs such as increased thirst or lethargy, and changes in urine output.

The documentation of this child's appearance (moist mucus membranes and normal cap refill) and vitals would indicate no to mild dehydration on presentation. The modest fluid resuscitation delivered for the first time prior to the premature decision to admit, gave the patient a buffer of additional hydration to permit oral repletion. Intravenous dextrose and fluids to clear ketones as well as subsequent oral Zofran would have been enough to permit adequate oral rehydration as per standard of care. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is not substantiated.