Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute gastroenteritis and possible asthma exacerbation.
Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.  The denial is upheld. 

This patient is a male child with a past medical history notable for asthma who presented to the Emergency Department (ED) of an outside hospital (OSH) by ambulance for assessment and management of fever, asthma exacerbation, and non-bilious, non-bloody vomiting (5 episodes) earlier in the day and watery non-bloody diarrhea (5-7 episodes).  The patient also experienced abdominal cramps.  The patient had received 2 albuterol treatments at home and 2 additional albuterol treatments from the Emergency Medical Services (EMS).  The patient's urine microscopic exam was notable for 50-100 white blood cells per high power field. The patient's chest x-ray and abdominal x-ray were unremarkable. The patient was given two 380 milliliters of normal saline boluses.  In addition, the patient received intravenous (IV) ceftriaxone, oral prednisone and Zofran.  The patient was transferred for suspected urosepsis/pyelonephritis.  The patient's physical exam indicated that the patient was alert and had moist mucus membranes.  The patient was not wheezing and had a normal cardiac exam.  The patient's abdominal exam showed hyperactive bowel sounds without pain, distention, rebound tenderness, or guarding; there was no organomegaly or masses noted.  The patient's admitting diagnosis was acute gastroenteritis and possible asthma exacerbation. While admitted, the patient received IV fluids.  The patient remained afebrile and vomiting/diarrhea did not recur.  The patient was discharged with instructions for outpatient follow-up.

Based on the review of the medical record and literature, acute inpatient hospital admission was not medically necessary for this patient. This patient appeared to have viral gastroenteritis with self-limited vomiting and diarrhea that resolved prior to this hospital presentation and mild dehydration that resolved with resuscitation at the prior hospital.  On arrival to this hospital, the patient's physical exam findings, laboratories and urinalysis suggested no dehydration, no evidence of asthma exacerbation and no persistent fevers.  Despite these clinical findings, the patient was immediately admitted to the inpatient unit.  

According to a review of the approach to acute viral gastroenteritis in children in resource-rich countries from UpToDate, the reasons to admit such an individual to the acute care setting would include signs of significant dehydration poorly responsive to intravenous hydration in the ED, 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 (bowel strangulation, appendicitis) or findings consistent with significant blood loss or bowel obstruction.  In this case, this patient met none of these criteria. In regards to this patient's volume status in a second review of dehydration in children from UpToDate, this patient was mildly dehydrated that resolved by the time he was admitted to the inpatient level of care.  The inpatient notes do not support intractable vomiting, poor oral tolerance or recurrent diarrhea.  This patient seems to have been admitted automatically after transfer without an independent assessment to confirm the need for inpatient services.  As could be predicted, the patient required no acute care after admission and was discharged less than 1 day after admission.  For these reasons, the acute care admission was not medically necessary for this patient.

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

The carrier's denial of coverage for the inpatient hospital admission should be upheld.  The medical necessity is not substantiated.