Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dehydration.

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 of asthma, cerebral palsy and hypothyroidism who presented to the Emergency Department (ED) for decreased oral intake, fatigue, nausea, and 2 episodes of vomiting in the last 2 days. There was no fever, abdominal pain, decreased urine output, dysuria or weight loss. There were no sick contacts. The patient's vital signs were: heart rate 134, temperature 98.3 Fahrenheit, respiratory rate 20, and blood pressure 110/73 and oxygen saturation 98% on room air. The admitting weight was 19.5 kilograms. Physical exam showed a well-developed, well-nourished male in no apparent distress. He was lethargic but alert. The patient's lungs were clear, he was tachycardic, and his abdomen was soft with normal bowels sounds. The patient's lab results showed: sodium 138, potassium 5.5, bicarbonate 10, blood urea nitrogen (BUN) 21, creatinine 0.82, glucose 63, and white blood cell (WBC) count 15 with left shift. The patient's venous blood gas was notable for potential hydrogen (pH) 7.33, partial pressure of carbon dioxide (PCO2) 31, partial pressure of oxygen (PO2) 36.5 and lactate 3.2. The patient received intravenous (IV) 390 milliliters (ml) of normal saline followed by 5% dextrose (D5) normal saline at 60.5ml/hr (hour). The patient was admitted for altered mental status, dehydration and high risk of sepsis. He received no anti-emetics, pain medication or antibiotics. No oral challenge occurred, and no vomiting recurred after presentation. The patient's heart rate was then 103. The patient was offered a regular diet that he tolerated well and his IV was lowered then stopped. The patient's repeat labs were notable for sodium 136, potassium 3.7, bicarbonate 19, BUN 10, creatinine 0.61, WBC count 6.5 without left shift, hemoglobin 10.7 and platelets 376. No additional treatment was given. At the time of discharge to home, heart rate was 120.
 
This patient appears to have had viral gastroenteritis with self-limited vomiting and mild dehydration that responded to IV fluid repletion. Exam, labs and vitals were unremarkable. Heart rate was similar at presentation as it was at the time of discharge. In accordance with a review of a child with nausea and vomiting from UpToDate, the reasons to admit would include signs of significant dehydration poorly responsive to IV hydration in the ED, hemodynamic instability, significant electrolyte imbalance, demonstrated oral hydration intolerance to oral challenge, poorly controlled pain, concerning physical exam findings for a surgical process or findings consistent with significant blood loss or bowel obstruction. This patient did not meet any of these clinical criteria. He was not offered or failed an oral hydration challenge. His vomiting had resolved before presentation and never recurred during this hospitalization.
 
In a review of dehydration in children from UpToDate, this patient's clinical appearance and vitals support mild dehydration that resolved by admission. After IV fluid resuscitation in the ED and observation, he could have avoided an unnecessary acute care admission. He was able to tolerate oral hydration and, after a period of observation, he could have been safely discharged. The low bicarbonate and venous lactate was corrected with fluids. Altered mental status amounted to an alert child that was lethargic prior to fluid resuscitation. Without fever, the patient did not meet accepted criteria for high risk for sepsis nor did the patient receive any sepsis treatment. 

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

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