Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting 

Treatment: Inpatient hospital admission 

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

This female infant presented to the ED (emergency department) with a 3-day history of vomiting and one day of fever [T (temperature) max 104 degrees F (Fahrenheit)] and congestion. Of note, this was the patient's second ED visit during the span of the acute illness. 
 
In the ED, the T was 102.2 degrees F (rectal), Pulse 167, Resp (respirations) 40. Labs in the ED were as follows: Bun (blood urea nitrogen) 4 (low per hospital lab norms), Cr (creatinine) 0.25 [WNL (within normal limits)], K (potassium) 5.6 (elevated), AST (aspartate aminotransferase) 55 (elevated), ALT (alanine transaminase) WNL, CO2 (Carbon dioxide) 18 (low). COVID (Coronavirus 2019) and Influenza Negative.

Evaluation by an attending in the ED, noted per their note: 3 days prior the patient developed NBNB (Non-Bloody Non-Bilious) vomiting about 10 times/day with only 2 wet diapers as compared to her baseline, 5-6 wet diapers. The patient was seen the day before in the ED for vomiting and was discharged home. On the day of presentation, the patient had a maximum T of 104 degrees F. Physical examination was notable for normal appearance, congestion, moist mucus membranes, tachycardia, and diaper dermatitis. The patient was diagnosed with "moderate dehydration and most likely viral gastroenteritis." Per the note, the "pt (patient) has been unable to have reliable PO (oral) intake with multiple ED visits for the same complaint." The plan was to "obtains labs and admit for IVF (intravenous fluids)." 

The patient was started on IVF D (dextrose) 5 NS (normal saline) maintenance, did not receive IV boluses, and no evidence that an antiemetic was given. The patient received IVF for a total of 12 hours. Repeat vitals were as follows, T 100.2 degrees F, HR (heart rate) 120, Resp 36. Later, the vitals were T 98.8 degrees F, HR 132, BP (blood pressure) 90/64. The patient was continued on her diet. On the resident's assessment, the "pt was active, alert with no signs of dehydration." 
  
A Practice Parameter issued by the American Academy of Pediatrics pertaining to children aged 1 month to 5 years has recommended that children with acute gastroenteritis with mild to moderate dehydration be treated with oral rehydration. (1) While oral rehydration is preferred, in children who fail oral rehydration, administration of rehydration fluids intravenously is effective and should be recommended. (2) According to 2014 guidelines for the management of acute gastroenteritis in children, indications of hospitalization for acute gastroenteritis in this population include shock, severe dehydration, neurological abnormalities [lethargy, seizures, etc. (and the rest)], intractable or bilious vomiting, failure of oral rehydration, and/or suspected surgical condition. (3) 

In this child's case, there was no clear evidence of dehydration, failure of oral rehydration, or intractable or bilious emesis. The tachycardia was likely secondary to fever. HR improved once the patient defervesced. The admission was less than 12 hours.
 
In the case of this child, the patient did not meet criteria for inpatient hospital admission as per the indications above. 

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.