Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Vomiting, abdominal pain with constipation.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld.

The inpatient admission was not medically necessary.

The patient is a male teen with medical history significant for hypertension, myocarditis, attention deficit hyperactivity disorder (ADHD), seizure disorder, severe constipation on routine Miralax, and global developmental delay that presented to the ED with two day history of vomiting, more than twenty times, as well as fever to 101, abdominal pain, and runny nose.  He had been hospitalized previously with refractory vomiting (cyclic vomiting) because of severe constipation, the most recent three months prior. 

Vital signs included temperature 36.9, heart rate 125, respiratory rate 20, and blood pressure 90/61.  Examination was significant for moist oropharynx, tachycardia, clear lungs, soft abdomen, and non-focal neurologic exam.  Laboratory evaluation was significant for mild metabolic alkalosis on venous blood gas, leukocytosis with white blood cell (WBC) count 20.80K, thrombocytosis with platelets 491K, hyperglycemia with glucose 136, and metabolic alkalosis with CO2 31.  He was given an intramuscular (IM) dose of Zofran as well as an intravenous (IV) fluid bolus.  He was offered a fluid challenge, which he failed. 

The patient was admitted to the Pediatric floor for further management of mild dehydration and vomiting.  Admission orders included maintenance IV fluids, regular diet, Zantac and Zofran, antipyretics as needed, continuation of home Keppra, gastroenterology (GI) consultation, and surgical consultation.  He had no further episodes of vomiting since admission but developed wheals after starting parenteral Keppra.  However, he had not passed a stool and was complaining of abdominal pain.  Abdominal x-ray was obtained concerning for sigmoid volvulus.  Surgical consultation was completed with no concern for volvulus, and recommendations for enema to induce a bowel movement followed by repeat x-ray.  The sigmoid changes had resolved after the patient passed a large bowel movement, with residual stool burden noted on repeat x-ray.  Bowel clean-out continued, with no further abdominal pain, no vomiting, and good appetite.  He was deemed stable for discharge at that time.

Constipation is not uncommon in childhood, and is typically functional in nature.  Functional constipation has a worldwide prevalence of about three percent.  In up to 40% of children, constipation begins in the first year of life.  Constipation is typically associated with painful stooling, abdominal pain, stool incontinence, and infrequent stooling.  In some, severe constipation may precipitate an episode similar to cyclic vomiting, with recurrent vomiting episodes severe enough to cause dehydration. 

The teenage male in this case had history of severe constipation that would precipitate refractory vomiting despite use of daily cathartic medications.  Prior to this admission, he had numerous episodes of vomiting along with some fever.  Lab results indicated contraction alkalosis from dehydration.  He failed treatment with an antiemetic in the ED and failed an oral challenge.  It was reasonable and appropriate to continue monitoring him in the hospital to manage his vomiting, dehydration, and constipation.  However, while hospital observation was medically appropriate, he was overall hemodynamically stable with no significant metabolic derangements.  He did not require acute inpatient admission and could have been safely managed at a lower level of care such as observation.