Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is upheld. 

This male patient has a past medical history notable for bilateral retractile testes and recent strep throat (day 6-7 of antibiotics) that presented to the Emergency Department (ED) for non-bilious non-bloody vomiting and abdominal discomfort. The patient's abdominal discomfort was intermittent involving the periumbilical area and bilateral lower quadrants. His abdominal exam showed low pitched bowel sounds with tenderness to palpation mostly in the low abdomen with voluntary guarding. There was no distention, rebound, organomegaly or masses. Laboratories were notable for sodium 130, potassium 4.2, serum bicarbonate 23, blood urea nitrogen (BUN) 8, creatinine 0.45, white blood cell (WBC) count 17.3 (70% neutrophils and 1 bands), hemoglobin 12.7, platelets 277, lipase less than (<) 20, c-reactive protein (CRP) 13.8 and a normal hepatic panel. A nasopharyngeal polymerase chain reaction (PCR) was negative for Influenza A/B/COVID. Imaging included an abdominal sonogram that showed edematous bowel without visualization of the appendix and an abdominal computed tomography (CT) that showed a normal appendix, thickened bowel (consistent with enteritis) and a left inguinal testis. He was given oral Tylenol and started on intravenous (IV) fluids. There was no further vomiting, but he did develop diarrhea after the oral contrast was given. His admitting diagnosis was acute gastroenteritis. He has no anti-emetics, no additional pain medications and maintenance IV fluids. A scrotal sonogram showed a left testis without torsion or lesion. He tolerated clears and was quickly advanced to a regular diet. No antibiotics were given until discharge. No additional laboratories were obtained. He remained afebrile and vomiting did not recur. 

This patient appeared to have viral gastroenteritis with self-limited vomiting that resolved prior to presentation and abdominal cramps without significant dehydration. The patient's physical exam findings, laboratories and imaging excluded worrisome conditions and his pain responded to oral Tylenol. According to a review of the approach to acute viral gastroenteritis in children in resource-rich countries from UpToDate (referenced), the reasons to admit such an individual to the acute care setting would include signs of significant dehydration poorly responsive to intravenous hydration in the ED, 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 (bowel strangulation, appendicitis) or findings consistent with significant blood loss or bowel obstruction. This patient met none of these criteria. 

This patient was not significantly dehydrated on presentation that resolved without fluid resuscitation. The inpatient notes do not support intractable vomiting, poor oral tolerance or persistent diarrhea (started after CT contrast was administered - a known cause of osmotic diarrhea). The patient required no acute care after admission. The acute care admission was not medically necessary and the child met none of the criteria to merit this level of care. 
 
The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for the inpatient hospital admission is upheld. The medical necessity is not substantiated.