Appeal type: Medical necessity
Decision: Overturned

Diagnosis Dehydration.
Treatment Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient presented with diarrhea since the morning prior to presentation. His mother stated that he had stools approximately 8 times per day. He also had decreased by mouth (PO) intake over this time. His mother brought him to the emergency room (ER) due to decreased activity and more fussiness. The patient drinks expressed breast milk and his mother also supplements this with formula. His mother has begun to introduce solids and started Greek yogurt 2 days prior to the onset of symptoms. There were no sick contacts at home. The patient had a diaper rash that the mother puts over-the-counter (OTC) cream on. There were no fevers, cough or runny nose and no vomiting. Upon presentation to the ER, vital signs were temperature 98.8 degrees Fahrenheit, heart rate (HR) 136, respiratory rate (RR) 32, oxygen saturation (O2 sat) 96%. Later on, the patient's temperature increased to 101.2 degrees Fahrenheit. On physical exam, the patient had moderate dehydration. He was given a normal saline (NS) bolus x2 and started on intravenous fluids (IVF) at 1.5M. Lab results revealed significant acidosis with a carbon dioxide (CO2) of 13. In the ER, he tolerated Pedialyte but had 2 more stools and after 3 hours, the basic metabolic panel (BMP) was repeated and CO2 decreased to 11, showing worsening metabolic acidosis. Stool for occult blood was positive. The patient was admitted to the floor for management of dehydration due to diarrhea and decreased PO intake. The physical exam at admission was unremarkable. He was admitted for IV rehydration in the setting of diarrhea and decreased PO intake. On the pediatric floor, he was started on IVF at 1M and given Pedialyte by mouth. Later the following morning, the patient lost his IV but maintained good PO intake. A repeat BMP showed an improved CO2 up to 20. His diet was advanced to breast milk which he tolerated well. He no longer had diarrhea and had 2 stools prior to noon that were formed. For the rest of the day, he continued to maintain good PO and urine output. He was deemed stable for discharge and was instructed to follow up with the primary medical doctor (PMD) in 24 hours.
At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was medically necessary for this patient. This patient presented with physical findings and also laboratory evidence of significant dehydration associated with a metabolic abnormality that persisted despite IV hydration. Apart from this, the patient had poor PO intake with frequent episodes of loose watery stools. This patient received 2 normal saline boluses in the ER. Even after this aggressive fluid resuscitation the patient's acidosis did not improve and his CO2 actually decreased further. While in the ER he did tolerate some PO Pedialyte but he also continued to have diarrhea. This patient would require IV hydration to compensate for his GI losses that he was unable to match orally. Based on these findings, this patient would meet criteria for inpatient admission for close monitoring of intake and output (I&O), IVF and repeat laboratory studies.
Per the literature current criteria for admission include:
1)	"caregivers cannot provide adequate care at home;
2)	Substantial difficulties exist in administrating oral rehydration therapy (ORT), including intractable vomiting, oral rehydration solution (ORS) refusal, or inadequate ORS intake;
3)	Concern exists for other possible illnesses complicating the clinical course; ORS treatment fails, including worsening diarrhea or dehydration despite adequate volumes;
4)	Severe dehydration (greater than [>] 9% of body weight) exists; Social or logistical concerns exist that might prevent return evaluation, if necessary
5)	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."
Due to the patient's inability to maintain hydration with adequate oral intake to compensate for his persistent frequent diarrhea and significant metabolic acidosis, an inpatient hospital stay was medically necessary.