Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diarrhea, Vomiting
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.


The patient is a female child who was referred to the emergency department (ED) by her pediatrician with a history of diarrhea with intermittent vomiting. There were multiple ill contacts in the household. The review of systems included malaise, no respiratory symptoms, no rashes, no change in wet diapers, tears with crying.  Examination was significant for lethargic appearance, moist mucous membranes, clear lungs, mildly distended abdomen with hyperactive bowel sounds, no guarding or rebound, no rashes, brisk capillary refill, and no focal neurologic deficits. She was diagnosed with acute gastroenteritis, given a dose of Zofran, and offered a by mouth (PO) challenge. A bedside glucose was 56. She tolerated bread rolls and a cookie. A subsequent bedside glucose was 64. Because of minimal change in her glucose, she was treated with a normal saline bolus and labs were obtained. Abnormal lab results were attributed to gastroenteritis and starvation ketosis. A repeat bedside glucose was 61. She was admitted for ongoing fluid resuscitation.
Admission orders included routine vital signs, regular diet for age, repeat bedside glucose, and maintenance intravenous (IV) fluids, probiotics, nutrition evaluation, endocrinology consultation, gastroenterology consultation, and serial abdominal exams. There were no endocrinology recommendations; her hypoglycemia was deemed secondary to depleted glycogen stores during illness and was improving over the course of her hospital stay. Gastroenterology recommendations included respiratory viral panel, stool studies, continued hydration, and outpatient follow-up. Her stools were normalizing, and she was tolerating her diet. The viral panel returned positive for adenovirus. She was deemed stable discharge. At issue is the medical necessity of an inpatient stay.

Inpatient hospital admission was not medically necessary for this patient.
Acute gastroenteritis is a major problem worldwide, representing one of the leading causes of morbidity and mortality in children. Most cases are caused by viruses, are self-limited, and require supportive treatment. According to the World Health Organization, oral rehydration therapy is the treatment of choice, particularly where diarrhea is the prominent feature and dehydration is mild to moderate. Intravenous rehydration is indicated when oral rehydration fails or when output is excessive. Output (vomiting, diarrhea) limits the success of oral rehydration, prompting use of anti-emetic medications. According to current guidelines for evaluation and management of acute diarrheal illness, people with fevers or bloody diarrhea, as well as severe cramping or signs of sepsis, should undergo diagnostic studies to determine if antimicrobial agents are appropriate. 
Hypoglycemia is a known complication in patients with acute gastroenteritis, particularly infants and young children. Duration of vomiting appears to be associated with development of hypoglycemia, often in conjunction with metabolic acidosis, and may be a useful indicator of severity of illness. This young child presented with a history of frequent watery diarrhea and intermittent vomiting. While it was reasonable to monitor this child in the hospital for resolution of dehydration, she was overall hemodynamically stable without refractory vomiting or evidence of impending circulatory collapse. She did not require acute inpatient admission and could have been safely managed at lower level of care.