Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Gastroenteritis

Treatment: Inpatient Hospital Admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

The patient is a female with eczema who presented to the Emergency Department (ED) with 7 episodes of non-bloody, non-bilious emesis.  While in the ED, she was found to have Rhino/enterovirus, given intravenous (IV) normal saline boluses twice, and IV Zofran.  She failed an oral challenge, had more episodes of emesis and was admitted to the pediatric service for IV fluid hydration.  IV fluids were continued on the floor with close monitoring of intake/output.
 	
This patient presented with multiple episodes of emesis with concern for dehydration (based on ED assessment period).  Although the patient was hemodynamically stable likely representing mild-mod dehydration (unable to assess a change in body weight, the patient was documented to appear very dry, and to have dry lips, dry mucus membranes and absence of tears when crying), she failed an oral fluid challenge administered in the ED with further episodes of emesis prompting admission for IV fluid administration.
 
The patient's admission was secondary to acute dehydration in the setting of an acute gastroenteritis, likely from Rhino/Enterovirus.  
 
A Practice Parameter issued by the American Academy of Pediatrics pertaining to children at an early age has recommended that children with acute gastroenteritis with mild to moderate dehydration be treated with oral rehydration.(1)  While oral rehydration is preferred, in children who fail oral rehydration, administration of rehydration fluids intravenously is effective and should be recommended.(2)  According to guidelines for the management of acute gastroenteritis in children, indications of hospitalization for acute gastroenteritis in this population include shock, severe dehydration, neurological abnormalities (lethargy, seizures, etc), intractable or bilious vomiting, failure of oral rehydration, and/or suspected surgical condition.(3) 

In this young patient's case, there was failure of oral hydration to maintain this patient.    
 
A publication from the MMWR [ Morbidity and Mortality Weekly Report (MMWR)] (of the CDC) states that regarding the management of acute gastroenteritis in children:  
 
"Inpatient care is indicated for children if:
 
-	Caregivers cannot provide adequate care at home;
-	Substantial difficulties exist in administrating ORT [oral rehydration therapy], including intractable vomiting, ORS [oral rehydration salts] refusal, or inadequate ORS intake;
-	Concern exists for other possible illnesses complicating the clinical course;
-	ORS treatment fails, including worsening diarrhea or dehydration despite adequate volumes;
-	Severe dehydration (>9 [percent]% of body weight) exists; 
-	Social or logistical concerns exist that might prevent return evaluation, if necessary, or;
-	Such factors as young age, unusual irritability or drowsiness, progressive course of symptoms, or uncertainty of diagnosis exist that might indicate a need for close observation."(4)

In the case of this child, as per the indications above (failed oral rehydration and further episodes of emesis in the setting of dehydration), inpatient care was warranted.  Discharging this patient home could have led to more severe dehydration and clinical compromise. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is reversed.  Medical Necessity is substantiated.