Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission. 
The denial is overturned.

The patient is a female with no significant past medical history who was born full term and with all vaccinations up to date. The patient presents with history of non-bloody, non-bilious vomiting x 4 days associated with multiple episodes of non-bloody diarrhea. Mother also reports patient had decreased by mouth (PO) intake and decreased urine output. As per mother, patient only took 4 ounces (oz) of PO the day prior and vomited afterwards. The patient has been having 10-15 diapers per day which are wet with brown mushy diarrhea. She was also vomiting three times per day with a watery color. She was having limited PO and only taking 12 ounce of water or a few sips of Pedialyte each day. Mother states patient became febrile over the past few days which made her concerned and prompted her to bring the child to the emergency room (ER) for further evaluation.

The patient was admitted for rehydration. Admission exam revealed patient with some decreased skin turgor, appeared mildly dehydrated overall. Capillary refill less than (<) 2 seconds, patient with mucous membranes described as moist but dry. The patient was well appearing and afebrile on the floor. No antibiotics were given. By the day of discharge diarrhea had improved. She was initially placed on intravenous fluids (IVF) which was weaned as tolerated. At the time of discharge, she was well appearing and hemodynamically stable. Patient was then cleared for discharge and instructed to follow up with primary medical doctor (PMD) in 1-2 days for re-evaluation. The subject under review is the medical necessity for the inpatient hospital admission.

The health plan's determination is overturned.

The requested Inpatient Hospital Admission was medically necessary for this patient. This  patient presented with history of fever, vomiting and diarrhea. This patient had findings on physical exam consistent with dehydration and also was found to have no urine in her bladder on a bladder scan in the ER. In addition, ER physician documented PO intolerance. In addition, she was found to be positive for both Salmonella and Campylobacter. Although Campylobacter is usually treated symptomatically, Salmonella, under certain circumstances may require antibiotic therapy and also carries a risk of bacteremia. Bacteremia can lead to endocarditis, abscesses, and osteomyelitis. Given her physical findings consistent with dehydration in conjunction with her PO intolerance, admission to inpatient level of care for rehydration and close monitoring of her input and output would be in the best interest of the patient. Current literature suggests admission for patients where "Substantial difficulties exist in administrating oral rehydration therapy (ORT), including intractable vomiting, oral rehydration solution (ORS) refusal, or inadequate ORS intake". Due to her inadequate oral intake as well as her significant physical findings on exam, an inpatient hospital stay is medically necessary. This patient's age is also of concern as dehydration may have a greater impact on hemodynamic stability given small total body volume and ability to compensate for losses.