Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Gastroenteritis

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld.

The patient was an infant with an unremarkable past medical history that presented to the Emergency Department for assessment and management of 5 days of watery, non-blood stools, fever prior to admission (PTA), non-bilious non-bloody vomiting and a diaper rash. His mother noted decrease oral intake and subjectively less urine output.  There was no associated pain, distention, weight loss or bleeding. The patient's vitals on arrival were notable for heart rate (HR) 134 Temperature 99.7 Fahrenheit, Respiratory Rate 26 and room air oxygen saturation of 98% (percent). Admitting weight was 8.448 kilograms and height was 72 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. There was mild nasal congestion. 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. His buttocks were erythematous. Admitting laboratories were notable for sodium 140, potassium 4.8, bicarbonate 21, blood urea nitrogen (BUN) 5, creatinine <0.3, glucose 88, white blood cell 3.3 (neutrophils 23%, no bands), hemoglobin 6.8 (error), platelet 214, C - Reactive Protein (CRP) 1.8 and a normal hepatic profile for age. Urinalysis was notable for specific gravity 1.010/pH (potential of hydrogen) 6.5 with trace ketones and blood. Nasal viral washings were positive for rhinovirus and negative for COVID (coronavirus). Repeat complete blood count within hours showed white blood cell 6.3 (neutrophils 21%, no bands), hemoglobin 11.7, platelet 350. No imaging was performed. He received a 20cc (cubic centimeter) per kilogram normal saline bolus that completed, followed by D5 (dextrose 5%) normal saline at 35 cc/hour. 
 
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 and oral intake improved after modest fluids were given and his low-grade fever 2 days prior to presentation never recurred.
  
The documentation of this child's appearance and vitals would indicate mild dehydration at best that responded to modest fluid resuscitation. The child failed to receive any intervention in the Emergency Department prior to the premature decision to admit him to the hospital for monitoring of strict intake and output. The fact that his serum bicarbonate was normal would suggest that stool losses were modest. A minimally elevated CRP and unremarkable complete blood count would suggest that a significant bacterial process was not present. After a brief period of hydration and 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. The child had no laboratory anomalies as referenced in the appeal. In regard to the acute inpatient admission the determination by the carrier that the admission was not medically necessary was correctly applied, objective, clinical valid, compatible with established principles of health care and flexible enough to permit justified variation. 

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

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