Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Viral Gastroenteritis. 
Treatment: Hospital Admission. 

The insurer denied coverage for hospital admission. 

The denial is upheld. 

The young infant had an unremarkable past medical history that presented to the Emergency Department for assessment and management of 16 days of watery, non-blood stools, "fever" to 99.9 F (Fahrenheit) and a diaper rash. The patient had been seen by his pediatrician and had a formula changed from Enfamil Gentlease to Enfamil Soy to Nutramigen without improvement. His mother noted 1 pound weight loss but the Pediatrician noted continued weight gain despite diarrhea.  There was no associated dehydration, distention, low urine output or pain. The patient's vitals on arrival were notable for Heart rate (HR) 109 Temperature 100.4 F, Respiratory Rate 33, and room air oxygen saturation of 100% (percent). Admitting weight was 8.1 kilograms and height was 68.8 centimeters. Physical exam showed an awake and alert male in no apparent distress. He had moist mucus membranes with normal capillary refill and normal skin turgor. Lungs were clear with normal effort. Cardiac exam was unremarkable. Abdomen exam was soft with normal bowels sounds. There was no associated tenderness, guarding, organomegaly, distension, rebound, or masses. There was no rectal exam reported. Admitting laboratories were notable for sodium 142, potassium 4.3, bicarbonate 26, BUN (blood urea nitrogen) 9, creatinine 0.2, glucose 81, white blood cell 9.8 (neutrophils 20%, no bands), hemoglobin 11.8, platelet 347, CRP (C-Reactive Protein) <0.29, lipase 32 and a normal hepatic profile. Urinalysis was notable for specific gravity 1.020/Ph (power of hydrogen) 7.5 and dip negative. Nasal viral washings were negative for Influenza A/B (type) and COVID (2019 Novel Coronavirus). No imaging was performed. No intravenous fluids or medications were administered. He was admitted to the inpatient service for observation and an elective gastroenterology consult with a diagnosis of viral gastroenteritis. He was changed to Alimentum formula with resolution of his diarrhea leading to formed, infrequent stool. Desitin was applied to his diaper rash. A gastroenterology consult was performed and recommended stool cultures, stool for oval and parasite (O&P), celiac markers, thyroid testing, and stool calprotectin - that were all normal. No antibiotics, pain medications or anti-emetics were given. Fever never recurred. He was discharge home for outpatient follow-up. 
  
This child appears to have had viral gastroenteritis with loose stools that responded to a formula change to Alimentum. He was admitted despite no hydration or red flags to suggest a serious condition.  In accordance with a review of the approach to diarrhea in children in resource-rich countries from UptoDate the reasons to admit such an individual would include signs of significant dehydration poorly responsive to intravenous hydration in the Emergency Department, hemodynamic instability, significant electrolyte imbalance, demonstrated oral hydration intolerance to oral challenge, poorly controlled pain with an oral pain medication regimen, concerning physical exam findings for a surgical process or findings consistent with significant blood loss or bowel obstruction. He did not meet any of these criteria to merit the inpatient setting. His loose stool at home and low-grade fever never recurred during the short admission after the correct formula choice. 
 
After a brief period of observation this patient could have been safely discharged with outpatient follow-up and parental reassurance. He actually received no acute care after admission to merit reimbursement at that level. This child met none of the criteria for admission cited in the appeal. 

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

Based on the above, the medical necessity for the hospital admission is not substantiated. The insurer's denial is upheld.