Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute gastroenteritis
Treatment: Inpatient admission
The insurer denied inpatient admission.
The health plan's determination is upheld. 

This patient is a female with no significant past medical history (PMH), who was admitted to the pediatric floor with dehydration and acute gastroenteritis. The patient presented to the emergency room (ER) with a two-day history of vomiting and diarrhea at home. On the day of presentation, the patient reportedly had no urine output for 12 hours prior to arrival, which is what prompted the family's visit to the ER. The patient was reportedly fussy, but consolable and had decreased oral intake. No other symptoms were reported at the time of presentation.
The patient was evaluated in the ER, where she was noted to have delayed capillary refill and dry mucous membranes on exam. 
Lab work was performed, which revealed an anion gap of 19 and initial blood glucose level of 65. Given her blood glucose, attempt was made to have the patient drink, but attempt was not successful. Repeat blood glucose was lower at 61, so the patient was given a bolus of dextrose 10% (D10) fluids. Once again, her blood glucose was repeated and was lower at 59, so a decision was made to give a second D10 intravenous (IV) fluid bolus and admit the patient for IV hydration with dextrose fluids, given her inability to maintain her blood glucose and hydration orally.
The patient was admitted inpatient to the pediatric floor for IV hydration. On the morning after admission, the patient was reported to have slept well with no further vomiting or diarrhea and had "several wet diapers during the night." Her recorded vital signs were within normal limits for her age. She was reported to appear playful and happy. On this day, IV fluids were discontinued, and the patient's diet was advanced from Pedialyte to formula. Once she was tolerating her formula well, the patient was cleared for discharge home.
At issue is the medical necessity of inpatient admission.

The requested health service/treatment of inpatient admission was not medically necessary for this patient.
At the time of presentation, the patient had signs of moderate dehydration/hypovolemia. These signs include markedly reduced urine output (no wet diaper for 12 hours), fussiness, and dry mucous membranes. In any patient, hypovolemia requires volume repletion. In all cases, the preferred method of volume repletion is via oral route, however this patient refused to take sufficient oral liquids in the emergency room and had a history of emesis at home prior to arrival. Given the patient's clinical signs of hypovolemia and inability to rehydrate via oral route, it is reasonable to expect that the patient would require IV hydration. While the patient's need for IV hydration would require a medical setting, it was not necessary that she remain as an inpatient. Within less than 48 hours from admission, the patient was tolerating oral fluids and aforementioned signs of moderate dehydration were resolved. Although IV rehydration was the appropriate action, given low blood sugar and signs of moderate hypovolemia, inpatient admission was not medically necessary.