Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vomiting, diarrhea and abdominal pain (gastroenteritis). 
Treatment: Inpatient admission. 

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

The patient is a female with medical history significant for tympanostomy tube placement that presented to the Emergency Department with a three-day history of vomiting and diarrhea, with blood present in both. She had decreased intake and suspected abdominal pain. She had no fevers. She was seen the day prior at an urgent care center and prescribed Zofran without relief. Vital signs included the following: temperature 37.4, heart rate 124, and respiratory rate 24. Examination was significant for non-toxic appearance, moist mucous membranes, tachycardia, clear lungs, upper abdominal tenderness, no blood in the diaper, no evidence of anal fissure, no urine in the diaper, brisk capillary refill, and non-focal neurologic exam. Laboratory evaluation revealed hyponatremia (sodium 131), hypoalbuminemia (albumin 3.1) with resultant apparent hypocalcemia (calcium 8.6), elevated alkaline phosphatase (194), significant leukocytosis with a white blood cell (WBC) count of 25.5K and 80% neutrophils, and negative coronavirus (COVID) testing. Abdominal ultrasound was significant for prominent fecal material in the right upper quadrant bowel loops, but the loops were compressible; peristalsis was noted and there was no definite evidence of intussusception. She was placed in Emergency Department observation status for serial assessments, intravenous (IV) fluid bolus, and diagnostic studies. She had no vomiting, but had diarrhea while in the Emergency Department with no evidence of blood. 

The patient was noted early on day two to be crying, refusing anything by mouth, with mild upper abdominal tenderness on exam. She continued to refuse fluids by mouth. She subsequently had an episode of vomiting treated with parenteral Zofran. She was admitted following observation for approximately five hours in the Emergency Department with ongoing abdominal pain, refusal to take anything by mouth, and ongoing vomiting/diarrhea. Admitting diagnosis included acute gastroenteritis and moderate dehydration. Admission orders included nothing by mouth, intravenous (IV) fluids, ceftriaxone following obtaining stool culture (blood culture sent), and repeat lab studies. Later in the day, the patient was able to tolerate a clear liquid diet. Repeat lab studies revealed resolution of hyponatremia, but development of hypokalemia (potassium 2.9), improvement in white blood cell (WBC) count (18.1K), anemia (hemoglobin 8.0), and thrombocytopenia (platelets 19K). She continued on intravenous (IV) fluids and ceftriaxone. Lab studies were repeated immediately, with concern for hemolytic uremic syndrome. Repeat metabolic panel revealed potassium near normal at 3.3. Repeat complete blood count (CBC) revealed worsening anemia with a hemoglobin of 7.2 and platelets at 17K. The patient was also noted to having increasing blood urea nitrogen (BUN) (11 > 23 > 28) and creatinine (0.32 > 0.76 > 1.07) levels indicative of progressive uremia and renal failure. She was subsequently transferred to a higher level of care for management of hemolytic uremic syndrome. 

Yes, the proposed acute inpatient admission was medically necessary and appropriate.
Abdominal pain is a frequent presenting complaint to both the clinic and the Emergency Department in the pediatric population, representing almost 10% of visits to the primary care office. A detailed history is essential in determining the etiology of pain, including associated symptoms, intensity, location, and previous episodes. Examination can be guided by presenting complaints. Guarding, rebound pain, and absent bowel sounds may be suggestive of need for surgical intervention. The differential diagnosis is somewhat age dependent and can be used to guide laboratory and radiographic evaluations. Across all ages, the differential includes appendicitis, bowel obstruction, constipation, gallbladder disease, gastroenteritis, mesenteric adenitis, pancreatitis, trauma, urinary tract infection, and upper respiratory infection. Additional causes include dietary indiscretion, trauma including child abuse, sickle cell crisis, and hemolytic uremic syndrome. For girls, menstrual-related conditions, pregnancy, pelvic inflammatory disease, and ovarian torsion should be considered. Abdominal migraine, functional abdominal pain, and mononucleosis may occur. Finally, intussusception, malrotation, Meckel diverticulum, and volvulus may cause abdominal pain. All factors must be taken into consideration when determining course of action. 

This young child presented with bloody stools and abdominal pain. She was initially observed in the Emergency Department for five hours with no change in condition and refusal to take anything by mouth. Following admission, serial labs revealed progressive uremia, rising creatinine, thrombocytopenia and anemia, all suggestive of hemolytic uremic syndrome likely secondary to ingestion of shiga toxin-producing E. coli (stool culture did not result in the documentation provided). Although the patient was able to tolerate clear liquids over the course of her hospital stay, with worsening acute kidney injury, hemolytic anemia and thrombocytopenia, she secured a diagnosis of hemolytic uremic syndrome and was transferred to a higher level of care. 

This child's clinical presentation, prolonged observation in the Emergency Department without improvement, and worsening illness over the course of her hospital stay prompting transfer to higher level of care all justify acute inpatient admission. A lower level of care would not have been safe or appropriate for this child. An acute inpatient level of care was medically necessary and appropriate.