Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Vomiting and diarrhea.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.

This is a patient with a past medical history notable for frequent spit-ups after feeds that presented to the Emergency Department for assessment and management of non-bilious, non-bloody vomiting over the last 5 days, loose stool x 2 days and known sick contacts. There was no associated GI (gastrointestinal) bleeding, decrease in appetite, dehydration, known weight loss or dysuria. The patient's vitals on arrival were notable for heart rate (HR) 116, blood pressure (BP) 103/56, Temperature 98.2 F (Fahrenheit), Respiratory Rate 30 and room air oxygen saturation of 99%. Admitting weight was 11.3 kilograms and height was 69 centimeters. Of note the patient was exclusively breast feed. Physical exam showed an alert, active male in no apparent distress. He had normal capillary refill (<2 seconds). Lungs were clear 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. Admitting laboratories were notable for sodium 136, potassium 5.2, bicarbonate 21, BUN (blood urea nitrogen) 4, creatinine 0.2, glucose 79, white blood cell 9.2 without a left shift (neutrophils 24.8%, no bands), hemoglobin 12.2, platelet 699, albumin 4.6, bilirubin 0.4, AST (aspartate aminotransferase) 44, ALT (alanine transaminase) 32, (alkaline phosphatase) 466 and lactate 2.3. No lipase or amylase were performed. No urinalysis was submitted for review. Nasal viral washings were negative for RSV (Respiratory syncytial), Covid and Influenza. Imaging included an abdominal sonogram that was unremarkable. He reportedly did not tolerate 3 oral challenges (no details) so was started on D(dextrose)5NS (normal saline) at 42 cc (cubic centimeters) /hour without a bolus with the decision to admit occurring one minute later. His admitting diagnosis was viral gastroenteritis. After admission he received one dose of intravenous Zofran. He vomited x 1, and that never recurred. He was given 2 intravenous doses of Pepcid followed by an oral dose the following morning. He tolerated Pedialyte and breast feeding. No repeat laboratories were performed. Two loose stools were noted. No additional anti-emetics were administered. No antibiotics were administered. He was discharged home for outpatient follow-up.
 
According to a review of vomiting in infants and children from UpToDate the authors notes that the reasons to admit such an individual would include signs of significant dehydration poorly responsive to intravenous hydration in the Emergency Department, 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 meet any of these criteria to merit the inpatient setting once receiving treatment with Zofran x 1. Intolerance to oral challenges in the Emergency Department without intravenous fluid resuscitation or Zofran does not constitute failed outpatient management. His elevated lactate likely represented the manner in which blood was obtained (venous) rather than secondary to tissue hypoperfusion.
  
Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is not substantiated.