Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Vomiting and dehydration

Treatment:  Inpatient admission 

The insurer denied coverage for inpatient admission.  The denial was reversed.

This patient is a male child who presented to the Emergency Department with complaints of emesis and generalized abdominal pain.  The patient was seen by his primary physician the previous day and was prescribed Amoxicillin for a sinus infection.  He had one dose of the Amoxicillin prior to arriving in the ED.  He was admitted to the pediatrics floor for vomiting and dehydration.  He was treated with intravenous fluids, IV Zofran, Motrin and Tylenol for fever.  He was noted to have tachycardia, but his electrocardiogram (EKG) was within normal limits.  A chest x-ray was negative.  He presented in the emergency department ED with the following vital signs: Temperature 38.1 C., Heart Rate (HR) 130, Respiratory Rate (RR) 20, Blood Pressure (BP) 90/62, oxygen Saturation (02) 100%.  The laboratory results were normal.  The patient was noted to be doing much better, and he was stable for discharge.  He received outpatient instructions to follow up with his pediatrician the next day associated with intermittent generalized abdominal pain.  The insurer has denied coverage for the inpatient admission.

According to a discharge summary, the patient presented with 1 day of vomiting, experiencing 8 episodes of emesis on the day of admission.  The patient also had generalized abdominal pain.  He had a soft bowel movement but no diarrhea.  He was seen by his Primary Care Physician (PCP) 1 day prior to admission for Upper Respiratory Infection (URI) symptoms and sore throat.  His PCP prescribed the antibiotic, Amoxicillin for a sinus infection.  He received a dose of Zofran (anti-emetic) at home.  He had a small amount of Pedialyte and water on the day of admission.  Of note, the patient's grandmother was being seen in the adult ED on the same day with the same symptoms. 

In this case, the patient presented with signs of mild dehydration.  The Practice Parameter issued by the American Academy of Pediatrics recommends that patients with acute gastroenteritis with mild to moderate dehydration be treated with oral rehydration (ref.1).  While oral rehydration is preferred, in children who fail oral rehydration, administration of rehydration fluids intravenously is effective and should be recommended (ref.2).  According to 2014 guidelines for the management of acute gastroenteritis in children, indications of hospitalization for acute gastroenteritis in this population include: shock, severe dehydration, neurological abnormalities (lethargy, seizures, etc.), intractable or bilious vomiting, failure of oral rehydration, and/or suspected surgical condition (ref. 3, 4).

This child presented with tachycardia, decreased oral tolerance, and inability to tolerate fluids or food by mouth (PO).  He was trialed on IV fluid bolus x 2 as well as 2 doses of Zofran without successful oral tolerance and reduction of tachycardia.  The tachycardia became such a concerning feature that an electrocardiogram (EKG) was done and cardiology was consulted. 

The health plan did not act reasonably with sound medical judgment or in the best interest of the patient.  Based on guidelines in the literature, this inpatient admission was appropriate.  The criteria used was MCG (22nd edition) Dehydration, Pediatric ORG: P-123 (ISC) and Dehydration: Observation Care OCG: OC-013 (ISC).

The medical necessity for the inpatient admission is substantiated.  The insurer's denial is reversed.