Appeal type: Medical necessity
Decision: Upheld

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

Patient was a teenager with a past medical history notable for depression/anxiety, obesity, asthma and chronic marijuana use that presented to the Emergency Department (ED) complaining of nausea, non-bloody non bilious vomiting x 4 days (7-8 episodes total), epigastric pain and decreased oral intake. There were no associated fevers, watery diarrhea, respiratory symptoms, weight loss, decreased urine output or dysuria. There were no sick contacts. The patient's vitals were notable for Blood Pressure 148/85, Pulse 100, Temperature 36.9 degrees C (Celsius), Respirations 22 and room air oxygen saturation of 100%. Physical exam showed an awake and alert obese female in mild-moderate distress. She had moist mucus membranes with normal capillary refill. Lungs were clear with normal effort. Cardiac exam was unremarkable. Abdomen exam was soft with epigastric discomfort to palpation. There was no associated organomegaly, distension, rebound, guarding or masses. There was bilateral flank pain noted. There was no rectal exam reported. Admitting laboratories were notable for sodium 143, potassium 4.2, bicarbonate 19, Blood urea nitrogen (BUN) 13, creatinine 0.72, glucose 94, amylase 122, white blood count 16.2 with a left shift (neutrophils 77%, no bands), hemoglobin 14.6, platelets 320,000 and a normal liver profile. Nasal swab was negative for Respiratory syncytial virus (RSV), COVID (coronavirus disease) and influenza A/B.

She was given Zofran 4 milligrams (mg) intravenous (IV) x 2, as well as antacid and ceftriaxone 3. She received two 1-liter boluses of Lactated Ringers  followed by Dextrose 5 % (D5) normal saline. An abdominal sonogram showed some gallbladder sludge. Her admitting weight was 97.1 kilograms, and her height was 176.5 centimeters. The assessment showed a calm patient in no apparent distress with pulse 78. A repeat urinalysis was notable for specific gravity 1.030, pH (potential hydrogen) 8 and dip 2+ for protein, 2+ ketones.  Once admitted she received Tylenol and Pepcid as well as Lasix for hypertension. She never vomited the entire admission. She never developed fever. No repeat labs were performed. No additional antibiotics were given. Additional studies showed negative cultures for chlamydia and gonorrhea and positive (+) for H. (Helicobacter) pylori antibodies. Toxicology screen was positive for cannabis. She was discharged home with a heart rate of 71.

This teen appears to have gastroenteritis with self-limited vomiting, mild dehydration and ketosis that resolved prior to admission to the inpatient setting. Although intake was overall decreased, she was never significantly dehydrated that resolved after modest fluid repletion. In accordance with a review of the approach to acute viral gastroenteritis 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. She 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.

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.