Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

 
Patient is a young child with a benign past medical history that presented to the Emergency Department (ED) complaining of intermittent non-bloody non-bilious vomiting, fevers, periumbilical abdominal pain, and decreased oral intake. There was no associated cough, rhinorrhea, congestion, wheezing, shortness of breath, tachypnea, weight loss, decreased urine output or dysuria. There were no sick contacts. Of note the patient presented 2 days earlier with similar complaints and was discharged after Zofran and Advil. The patient's vitals were notable for Blood Pressure 113/68, Pulse 139, Temperature 102.7 degrees F, Respiration 24 and room air oxygen saturation of 100%. Physical exam showed an awake and alert male in no apparent distress. He had moist mucus membranes with normal capillary refill. Lungs were clear with normal effort. Cardiac exam was unremarkable. Abdomen exam was soft and flat. There was no associated pain, organomegaly, distension, rebound, guarding or masses. There was no rectal exam reported. 

Admitting laboratories were notable for sodium 129, potassium 4.6, bicarbonate 24, Blood urea nitrogen (BUN) 9, creatinine 0.31, glucose 84, white blood count 16.2 with a left shift (75% neutrophils, no bands), hemoglobin 11.3, platelets 227,000, and C reactive protein (CRP) 6. No amylase or lipase assessed. Respiratory viral panel was negative. 

This child appears to have a viral gastroenteritis with self-limited vomiting and minimal dehydration that resolved prior to admission to the inpatient setting. Although intake was overall decreased, he was never significantly dehydrated; that resolved after modest fluid repletion. In accordance with a review of the approach to acute viral gastroenteritis in resource rich countries in infants and children from UpToDate 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. He did not manifest any of these criteria to merit the inpatient setting. Certainly, whatever vomiting that was occurring in the outpatient setting was never intractable or persistent after assessment and treatment in the ED (never recurred throughout the admission). Although given antibiotics starting more than 12 hours after presentation x 48 hours, he never was felt to be septic and could have taken oral agents after the initial ceftriaxone dose. His nausea was successfully treated with oral Zofran in the ED and this could have been continued as needed in the outpatient setting. His hyponatremia from taking excess free water would have corrected with appropriate oral rehydration therapy after initial intravenous repletion. Lastly, he had no significant pain when examined despite this being one of his presenting symptoms.

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 the inpatient admission is not substantiated.