Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Adenovirus gastroenteritis
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

The patient is an infant with a past medical history notable for prematurity (27-week gestation), bronchopulmonary dysplasia, pulmonary hypertension, gastroesophageal reflux, Respiratory Syncytial Virus (RSV), bronchiolitis, repaired bilateral inguinal hernias, repaired rectal prolapse, recent cerclage removal, and recent adenovirus gastroenteritis. The patient presented to the Emergency Department (ED) with fatigue, decreased oral intake for 2 days, intermittent vomiting/spitting up, and soft stools with some blood streaked mucus for 1-2 days. Of note, the patient had been evaluated 2 days earlier in the same ED and was diagnosed with adenovirus in stool. The child returned because the blood in stool was new as was the fatigue. 

There was no associated pain, fevers, watery diarrhea, weight loss, or dysuria. Other family members had upper respiratory tract symptoms. The patient's vitals were notable for Pulse 136, Temperature 37.2 degrees Celsius, Respiratory Rate 38 and room air oxygen saturation of 97% (percent). Physical exam showed an awake and alert infant in no apparent distress. He had "somewhat dry" mucus membranes (triage documentation notes moist mucus membranes) with normal capillary refill. Lungs had referred upper airway breath sounds with normal effort. Cardiac exam was unremarkable. Abdomen exam was soft. There was no associated pain, organomegaly, distension, rebound, guarding or masses. There was no rectal exam reported. 

He received one Normal Saline bolus followed by Dextrose 5% (D5) Normal Saline. He was tolerating 2-4 ounces of Gentlease every 2 hours. A chest X-ray showed chronic right upper lobe (RUL) and left basilar atelectasis without change. An abdominal X-ray showed non-specific dilated bowel loops. The patient was admitted for dehydration. 

This child appears to have adenovirus gastroenteritis with self-limited vomiting, blood-streaked soft stool and mild dehydration in the setting of a complex medical history. Although intake was overall decreased, he was never significantly dehydrated. He clearly demonstrated the ability to hydrate orally and was noted to be drinking while in the ED. In accordance with a review of the approach to acute viral gastroenteritis in resource rich countries in infants and children from UpToDate, the reasons to admit such an individual would include signs of significant dehydration poorly responsive to intravenous hydration in the ED, significant weight loss, profound lethargy, hemodynamic instability, significant electrolyte imbalance, demonstrated oral hydration intolerance to oral challenge, poorly controlled pain with an oral pain medication regimen, concerning physical exam findings for a surgical process, or findings consistent with significant blood loss or bowel obstruction. He did not manifest any of these criteria to merit the inpatient setting. Certainly, whatever vomiting that was occurring in the outpatient setting was never intractable or persistent at time of assessment in the ED.

The documentation of this child's appearance and vitals would indicate minimal dehydration on presentation that resolved with modest fluid resuscitation and maintenance fluids. In the setting of a benign abdominal exam, normal white blood count, unremarkable inflammatory markers and known adenovirus he was postulated to have enterocolitis. He appeared to be admitted more for his past medical history rather than for the acuity of his current state. Intravenous hydration followed by oral hydration would have been standard of care for this child. 

Based on the above, the insurer's denial must be upheld. 

The medical necessity for the inpatient hospital admission is not substantiated.