Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Gastroenteritis.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.
The denial is overturned.

The patient is a male with speech delay who presented to ED (emergency department) with diarrhea, vomiting, abdominal pain, decreased oral intake x1day. In ED, he was noted to be dehydrated with tachycardia, sunken eyes and dry lips. He was given IV (intravenous) NS (normal saline) bolus, Zofran IV and started on maintenance IV fluids. After failing a po (oral) challenge, patient was admitted for further management of acute gastroenteritis. IV fluids were continued, and the patient's intake/output was closely monitored. 
 
This young child presented with significant diarrhea, abdominal pain, multiple episodes of emesis with poor PO intake and symptoms/signs consistent with moderate clinical dehydration (based on tachycardia, dry mouth, cap refill less than 2 seconds, sunken eyes, abnormal sleepiness, and decreased urine output with elevated Bun/Cr on bloodwork). Discharge weight not available to assess % (percent) loss of body weight. Patient failed an oral fluid challenge administered in the ED with ongoing episodes of emesis and diarrhea prompting admission for IV fluid administration and further care. Gastrointestinal infectious panel was positive for Norovirus, Campylobacter and Giardia.
 
Below references will be used to support reasoning for hospitalization. 
  
A Practice Parameter issued by the American Academy of Pediatrics pertaining to young children 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 child's case there was evidence of dehydration, with ongoing emesis and failure of oral rehydration.
 
A publication from the MMWR [Morbidity and Mortality Report) (of the CDC [Center for Disease Control]) 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 oral rehydration therapy (ORT), including intractable vomiting, ORS [oral rehydration solution] 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 (refused to drink) in the setting of moderate dehydration and ongoing emesis and diarrhea), inpatient care was warranted. 
Discharging this patient home per insurance recommendations could have led to severe dehydration and clinical compromise. 

The denial of coverage should be overturned as the inpatient admission was medically necessary for this patient.

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

The insurer's denial of coverage is overturned. Medical Necessity is substantiated.