Appeal type: Medical necessity
Decision: Upheld

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

This patient with a history of (h/o) Trisomy 21, atrioventricular (AV) canal defect status/post (s/p) repair and asthma presented with several days of vomiting and diarrhea. 2 days prior, the patient had multiple episodes of non-bloody, nonbilious (NBNB) emesis after school with a decreased tolerance for by mouth (PO) intake and a few episodes of watery loose NB diarrhea. She was seen in the emergency department (ED) at that time and received intravenous fluids (IVF), passed a PO challenge, and was subsequently discharged home.
On the day prior to admission, the patient's emesis improved with decreased episodes, but her diarrhea episodes increased, and they were all still watery. Her mother was giving Pedialyte, and she was tolerating small sips. She presented to the ED due to diarrhea. The last fever was two days prior to the ED of 100.8 degrees Fahrenheit per the mother. She had no fevers on the day prior. The patient was in contact with sick peers at school. Apparently, multiple other children were staying home for vomiting/diarrhea per the mother. The patient was found to be Flu B positive two weeks ago and completed a course of Tamiflu without issue. She was also given a course of Cefdinir, last dose 4 days prior to left ear pain when seen by her primary medical doctor (PMD). The patient no longer had a cough or ear pain since two days prior.
In the ED, she was afebrile with a heart rate (HR) of 111, normotensive, had a normal respiratory rate (RR), and oxygen saturation (O2 sats). Lab results showed venous blood gas (VBG) grossly normal and a complete blood count (CBC) unremarkable. The basic metabolic panel (BMP) showed a sodium of 136, carbon dioxide (CO2) 21. A stool culture and rotavirus were sent. The ED exam documented the child to appear hydrated with moist oral mucosa and normal capillary refill. Normal saline (NS) bolus was administered in the ED. She was admitted to the pediatric floor for treatment of dehydration. The last heart rate (HR) recorded in the ER prior to transfer to the floor was 78. The admission exam documented the child to be well appearing and appearing hydrated. The oral mucosa was minimally dry, capillary refill 2-3 seconds. The assessment on admission was patient clinically looks well but sleepy and more tired than usual. She was tolerating some PO fluids. On the floor, her PO intake improved with adequate urine output. She remained afebrile with stable vital signs. On the morning after admission, it was reported that she had no episodes of diarrhea overnight, and she slept well throughout the night without any abdominal pain. That morning the patient drank 4 ounces (oz) of apple juice and was behaving normally per the mother, laughing and playing with her father. Her diarrhea improved to about 1-2 episodes on the day of discharge. Her stool culture grew negative for 24 hours, and her rotavirus culture returned positive. On the day of discharge, horizontal nystagmus was noted on the exam, which the mother states was not noticed before. Ophthalmology recommended outpatient evaluation. The patient was then deemed stable for discharge with adequate PO intake. She was advised to follow up with her primary medical doctor (PMD). She also was scheduled to see Ophthalmology.
At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was not medically necessary for this patient. The patient responded to ER resuscitation of normal saline bolus followed by IV fluids. There was no mention of a failed PO trial in the ER after she received her IVF bolus, as oral rehydration is the recommended first-line for mild to moderate dehydration. The patient had normal laboratory studies as well as normal vital signs. Her HR at triage was 111, and prior to leaving the ER and at the time of transfer to the floor, it was 78. On the morning after admission, it was reported she had no episodes of diarrhea overnight, and she slept well throughout the night without any abdominal pain. That morning, the patient drank 4 ounces (oz) of apple juice and was behaving normally per mother, laughing, and playing with father. She did not have any severe abdominal tenderness, hemodynamic instability, vomiting that was severe or persistent, nor did she demonstrate an inability to maintain oral hydration. She did not require any highly skilled or intensive care while admitted. The inpatient level of care was not medically necessary.