Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain and Vomiting.
Treatment: Inpatient Admission.
The insurer denied: Inpatient Admission.
The denial is upheld.

The patient is a toddler male child with history significant for asthma, speech delay, and febrile seizures. He presented to the ED (emergency department) with week-long history of fevers and vomiting. He had been to the ED (emergency department) five times over the prior two weeks (including once for febrile seizure), most recently a week earlier. Initially, he was diagnosed with an acute viral process and chest x-ray findings consistent with viral illness or reactive airways disease. Viral screening was negative. He returned with persistent fevers, cough, and febrile seizure. At that time, he was diagnosed with right otitis media and prescribed azithromycin. He developed rash with azithromycin was prescribed Bactrim as well as prednisolone for five days. After completing the Bactrim course, he began having episodes of vomiting. The patient was seen in an ED (emergency department) and prescribed ondansetron. The patient's vital signs included temperature 37.5, heart rate 97, respiratory rate 28, and blood pressure 112/88. The patient's examination was significant for moderate distress but appearing healthy and alert, dry mucous membranes clear lungs, regular heart rate and rhythm, non-tender abdomen, and non-focal neurologic exam. Bedside glucose was 49. Laboratory studies were significant for hyperkalemia with potassium 5.2, metabolic acidosis with CO2 (carbon dioxide) 12, hypoglycemia with glucose 64, mildly elevated creatinine for age 0.55, normal CRP (C-reactive protein) 0.7, venous lactate 3.3, normal WBC (white blood cell) count 8.9K (thousand). The patient was treated with an IV (intravenous) fluid bolus as well as D10 (10% dextrose), with repeat bedside glucose 71. He was also given a dose of ondansetron for nausea. The patient's admission orders included maintenance IV (intravenous) fluids, consideration for stool testing for Clostridium difficile, consideration for repeat lab studies, routine vital signs. Overnight, he improved significantly, with adequate oral intake and improvement on repeat lab studies. He was deemed stable for discharge home the next day.

The Inpatient Admission was not medically necessary.

Acute gastroenteritis is a major problem worldwide, representing one of the leading causes of morbidity and mortality in children. There are an estimated 2.5 million deaths each year attributable to gastroenteritis in children under the age of 5 years. Most cases are caused by viruses, are self-limited, and require supportive treatment. According to the World Health Organization, oral rehydration therapy is the treatment of choice, particularly where diarrhea is the prominent feature and dehydration is mild to moderate. Intravenous rehydration is indicated when oral rehydration fails or when output is excessive. Vomiting limits the success of oral rehydration, prompting use of 
anti-emetic medications. Hospitalization may be necessary for those that do not respond to oral hydration and anti-emetic treatment, as well as those with severe dehydration and/or ongoing fluid losses that cannot be successfully managed with oral rehydration. This child presented for recurrent vomiting and fever after having been treated for multiple other illnesses (viral syndrome, otitis media) complicated by febrile seizure, adverse reaction to the first antibiotic, and reactive airways disease. He presented at this time (after numerous visits) for vomiting and fever. He exhibited both physical and biochemical signs of dehydration. While it was appropriate to treat the dehydration and monitor for ability to tolerate sufficient fluids, he was overall hemodynamically stable with no evidence of impending shock or 
sepsis. He did not require acute inpatient admission and could have been safely managed at a lower level of care, such as observation.