Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dehydration and acute gastroenteritis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial is upheld.

This patient is a female with a past medical history notable for reactive airway disease and recent right upper lobe pneumonia who presented to the Emergency Department (ED) for assessment and management of non-bloody, non-bilious post-tussive vomiting for 1 day (reported 3-4 episodes), non-bloody diarrhea without mucus, and fungal diaper rash. The diarrhea was associated with taking oral Amoxicillin. The patient was refusing solids but was tolerating liquid intake (although subjectively less milk). There was no associated fever, bleeding, weight loss, change in urination or change in activity. Of note the patient was seen the prior day in the same ED with hives and was treated with Benadryl and discontinued oral Amoxicillin.

The decision to admit the patient was made prior to any intravenous fluids for diagnoses of dehydration and acute gastroenteritis. The patient was offered a clear diet for which she tolerated but was then treated with bowel rest for 24 hours. The patient's vomiting did not recur. The patient remained afebrile, and her heart rate ranged from 98 to 144 and was 133 at discharge.

Based on the review of the medical record, this patient had antibiotic-associated diarrhea exacerbated by acute viral gastroenteritis (confirmed by stool PCR for astrovirus) with self-limited vomiting, watery diarrhea and minimal dehydration that responded to modest intravenous (IV) repletion. The patient's physical exam, laboratories and vitals were for the most part unremarkable (serum bicarbonate was low secondary to stool losses). 

According to the review of the approach to nausea and vomiting in children from UptoDate, the reasons to admit a patient includes signs of significant dehydration poorly responsive to intravenous hydration in the Emergency Department, hemodynamic instability, significant electrolyte imbalance, demonstrated oral hydration intolerance to oral challenge (after treatment with anti-emetics and fluids), 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. In this case, this patient did not meet any of these clinical criteria to warrant inpatient level of care. On exam, tis patient was noted to have moist to slightly dry mucus membranes, normal skin turgor, normal capillary refill, crying with tears, and preserved urine output. The patient's heart rate on admission was the same as on discharge. The patient's volume status was at most minimal to mild dehydration. And based on the review of the medical records, the patient did not receive any intravenous (IV) fluid prior to the decision to admit the patient. This lack of intervention to address this patient's mild dehydration was inadequate to merit 'failed outpatient management' criteria for inpatient admission. 

The patient's vomiting resolved and was able to tolerate oral hydration prior to and throughout her inpatient admission. This indicates that this patient's care could have been provided at an observation level of care. After a brief period of observation and monitoring, this patient would have likely been safely discharged with outpatient follow-up. The care that the patient received as inpatient was primarily intravenous fluids, which could have been safely provided at the observation level of care. Thus, inpatient admission was not medically necessary to treat this patient's medical condition.

The health plan acted reasonable with sound medical judgment, and in the best interest of the patient.