Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dehydration

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

Patient was a child with a past medical history of Heliobacter (H.) pylori that presented to the Emergency Department (ED) complaining of non-bloody, non-bilious vomiting intermittently x several days, non-bloody diarrhea x 2-3 days, decreased oral intake, fussiness and fever 2 days ago. There was no associated wheezing, shortness of breath, weight loss, or dysuria. The patient was eating poorly but was tolerating Pedialyte at home. The patient's sibling had recent gastrointestinal (GI) symptoms that resolved. The patient's vitals were notable for heart rate 90, temperature 37.2 degrees Celsius (C), respirations 26, and room air oxygen saturation of 100% (percent). Physical exam showed an alert, fussy child in no apparent distress. The patient had dry mucus membranes and 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 134, potassium 5, bicarbonate 17.5, Blood Urea Nitrogen (BUN) 12, creatinine 0.34, glucose 61, serum lactate 2.26, white blood count 13.1 without a left shift (neutrophils 31%), hemoglobin 12.8, and platelets 450. Throat strep test was negative. Respiratory viral panel was negative for influenza A/B, respiratory syncytial virus (RSV) and Covid. No urinalysis was submitted for review. The patient's admitting weight was 15 kilograms (kg). The patient received one 300 milliliter (ml) boluses of normal saline followed by Dextrose 5% (D5) normal saline at 50 ml/hour. In addition, the patient was given Dextrose 50% (D50) 12.5 grams (gm) intravenous push and Zofran 2 milligrams (mg) intravenously. Imaging included a chest x-ray suggesting viral bronchiolitis without focal infiltrate. The decision to admit the patient to the inpatient unit for dehydration and hypoglycemia in the setting of acute gastroenteritis occurred. Once admitted the patient received intravenous fluids with oral diet as tolerated. No diarrhea or vomiting occurred throughout the admission. The patient remained afebrile. 

The documentation of this child's appearance (dry mucus membranes and normal capillary refill) and vitals/weight would indicate mild dehydration on presentation that resolved prior to the decision to admit. The modest fluid resuscitation delivered in the Emergency Department had just completed when the decision to prematurely admit to the inpatient setting occurred. In fact, Zofran was given hours after admission and not urgently as stated in the appeal. A nursing note documented the child was strong, playful, drinking well and stooling/voiding. Intravenous dextrose and fluids to clear ketones would have been enough to permit adequate oral rehydration as per standard of care. The patient appeared to be admitted for observation and supplemental intravenous fluids despite not being given an oral challenge and already tolerating oral hydration. The patient's elevated lactate was likely related to a venous sample and not from poor tissue perfusion. This patient actually never received any acute care after admission to the inpatient setting to merit reimbursement at this level. The patient's heart rate at discharge was higher than at presentation even after intravenous fluids.

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 an inpatient hospital is not substantiated.