Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Gastroenteritis
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld.

This is a pediatric patient with a past medical history of language delay and recent otitis media that presented to the Emergency Department for assessment and management of fever, non-bloody watery diarrhea, non-bilious non-bloody vomiting and decreased oral intake. He continued to have wet diapers. There was no associated gastrointestinal (GI) bleeding, pain, known weight loss, lethargy, rashes, cough or sick contacts. Of note, the patient was on day 4 of Amoxicillin for otitis media. The patient's vitals on arrival were notable for heart rate (HR) 177, Temp 103 degrees Fahrenheit, and room air oxygen saturation of 97% (percent). Admitting weight was 12.1 kilograms (kg). Physical exam showed a non-toxic male in no apparent distress. He had dry mucus membranes, dry lips and was crying without tears. He had capillary refill < 2 seconds. Lungs were clear with normal effort. Cardiac exam was unremarkable. Abdomen exam was soft. There was no associated pain, organomegaly, distension, rebound, guarding or masses. There was no rectal exam reported. Admitting laboratories were notable for sodium 135, potassium 4.6, bicarbonate 12, Blood Urea Nitrogen (BUN) 10, creatinine 0.43, glucose 114, albumin 5.1, bilirubin 0.3, aspartate transaminase (AST) 42 and alanine transaminase (ALT) 20. No urinalysis was submitted for review. Nasal viral washings were negative for respiratory syncytial virus (RSV), COVID (coronavirus disease) and Influenza A/B. He was admitted for acute gastroenteritis and moderate dehydration. His vomiting resolved but loose stools persisted. His weight on the floor was 12.6 kg (kilogram) and his height was 90 centimeters. 
 
This child had viral gastroenteritis (self-limited vomiting and loose stools) and mild-moderate dehydration that resolved by the time of admission to the inpatient setting. He did appear dehydrated on presentation but significantly improved with fluid resuscitation prior to admission. He did demonstrate the ability to tolerate oral intake and rehydration when offered (drinking apple juice in the Emergency Department). 

In accordance with a review of the approach to acute viral gastroenteritis in infants and children from UpToDate authors conclude the following: Acute viral gastroenteritis usually is self-limited. It is treated with supportive measures (e.g., fluid repletion and unrestricted diet). No specific antiviral agents are available for the treatment of acute viral gastroenteritis. Fluid repletion and replacement of ongoing fluid losses are the goals of therapy for acute viral gastroenteritis, whether the child is managed at home, in the emergency department, or in the hospital. Fluid repletion is based upon the degree of hypovolemia (dehydration) and presence of hyper- or hyponatremia. Severe hypovolemia requires rapid intravenous isotonic fluid resuscitation. Oral rehydration therapy (ORT) is the preferred first-line treatment for children with mild to moderate hypovolemia.

The documentation of this child's appearance, his vitals and the weight percentage difference (3-4%; 12.1 from 12.6 kilograms) after hydration would indicate mild dehydration on presentation that resolved with intravenous resuscitation. His presenting heart rate exaggerated his degree of dehydration since he was febrile to 103 Fahrenheit at the time and crying. His laboratory abnormalities were not critical and would be expected to correct with fluid resuscitation to clear ketones followed by oral rehydration therapy. He appeared to be admitted more for observation than the severity of his condition at presentation. After admission he was merely observed with both intravenous and oral fluids, and safely discharged on oral fluids with outpatient follow-up shortly after admission.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.