Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dehydration
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

This patient is an infant with a past medical history of Respiratory Syncytial Virus (RSV) that presented to the Emergency Department for assessment and management of fever, intermittent non-bilious non-bloody vomiting, cough, congestion, decreased oral intake and decreased urine output (1-2 wet diapers in the last 24 hours) over the last 5 days. The patient's vitals on arrival were notable for heart rate 163 (crying - repeat 130), Temperature 100.9 degrees Fahrenheit (F), respiratory rate 35 and room air oxygen saturation of 100%. The admitting weight was 15.6 kilograms and the height was 91.5 centimeters. The physical exam showed an alert, non-toxic infant in no apparent distress. The infant had mildly dry mucus membranes and a normal capillary refill (< (less than) 2 seconds). Admitting laboratories were notable for sodium 142, potassium 5, chloride 111, bicarbonate 18, blood urea nitrogen 11, creatinine 0.43, glucose 73 (bedside 69), white blood cell 18.3 without a left shift (neutrophils 53%, no bands), hemoglobin 12.6, platelet 415, C-reactive protein (CRP) 7.5, and a erythrocyte sedimentation rate (ESR) of 62. Imaging included a chest x-ray that was notable for mild peri-bronchial thickening without focal infiltrate. The patient received a 20 milliliter per kilogram normal saline bolus followed by Dextrose 5 normal saline at maintenance. A urinalysis was notable for specific gravity 1.025, acidity PH (potential for hydrogen) of 6. A urine dip was positive for trace protein, 4+ (plus) ketones and large amount of blood (traumatic). Nasal viral washings were negative for Coronavirus (Covid), RSV, Influenza A and B. The decision to admit the infant for observation and hydration occurred for poor intake and dehydration. The max temperature during the admission was 101 degrees F. The patient received intravenous fluid until the intravenous line infiltrated. The patient had small emesis a few hours prior to discharge. No repeat laboratories were performed. The patient never showed signs of respiratory distress and the patient never required supplemental oxygen. Then the infant received no antibiotics or additional anti-emetics. The heart rate at discharge was 113.

The reasons to admit such an individual would include signs of significant dehydration poorly responsive to intravenous hydration in the Emergency Department, significant weight loss, profound lethargy, 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. The patient did not meet any of these criteria to merit the acute inpatient setting. The metabolic acidosis was secondary to ketosis not poor tissue perfusion that would clear with dextrose/hydration in the Emergency Department. Refusing to drink in the Emergency Department does not constitute oral intolerance.

Uphold denial of coverage for acute inpatient admission. Approve at the observational level of care.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is not substantiated.