Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal/Abdominal Pain
Treatment: Inpatient Emergency Admission
The health plan denied the requested inpatient emergency admission as not medically necessary. 
The health plan's determination is upheld.

The patient is a female, with a past medical history of poor weight gain and malnutrition. She presented to the emergency department (ED)  with abdominal pain, vomiting and diarrhea that were ongoing for the past 2 days. She had 8-10 episodes of nonbilious nonbloody vomitus. Vitals were normal in the ED, and she was afebrile. It was noted that the patient was small for her age. She was given intravenous (IV) fluids (10 milliliters/kilogram (ml/kg) bolus x1 and 20 ml/kg x1, then dextrose 5% and normal saline at maintenance) and Zofran. Lab work done in the ED were notable for a carbon dioxide (CO2) of 14, a glucose of 57, an anion gap of 22, and a C-reactive protein (CRP) of 1.2. A stool was sent and returned positive for adenovirus and norovirus. ED documentation reports no urine output, poor weight gain, and poor oral effort, concern for acute gastroenteritis, overlying or exacerbation of a chronic condition such as malabsorption, inflammatory bowel disease (IBD), and poor intake/behavioral.
The patient was consulted by gastroenterology and nutrition. Gastroenterology recommended obtaining thyroid and celiac studies and follow as an outpatient and starting Cyproheptadine. A nutritionist noted that she met severe malnutrition with her z-score and recommended increasing caloric intake with Pediasure 1.0 or Carnation Breakfast Essentials with whole milk each meal. Overnight, she had poor oral intake and was continued on IV fluids at maintenance. On the morning of discharge, the patient had oral intake, and no complaints overnight of vomiting, diarrhea or abdominal pain and had urine output. She was remained hemodynamically stable and was discharged home with gastroenterology follow up.
The issue under review is whether the inpatient admission was medically necessary.

The health plan's determination of medical necessity is upheld, in whole.

It was unclear from the medical records provided if this patient could not have trialed oral rehydration and electrolyte solutions at home, or continued care in the emergency department for the concerns of poor oral intake. ED documentation showed no concerning vital signs, or physical exam findings. There was mention of epigastric pain, but an otherwise soft abdomen.
The American Academy of Pediatrics (AAP) published practice guidelines for the treatment of dehydration secondary to gastroenteritis that advocates for the use of oral rehydration therapy (ORT) over intravenous (IV) rehydration. In a Cochrane review involving 17 trials and 1811 children with acute gastroenteritis, it was demonstrated that ORT had equivalent success rates when compared with IV rehydration.
In 2020, the AAP performed a single-center quality improvement initiative between 2010 and 2016, where the investigators aimed to decrease the percentage of patients with gastroenteritis who were rehydrated with IV fluid. They implemented a dehydration evidence-based guideline (EBG) and concluded that it led to a decrease in frequency of IV administration, shorter lengths of stay, and lower health care costs.
Using the EBG provided in this initiative for this patient, would have placed her under the mild dehydration score. It appears there was also concern for patient's weight and underlying chronic issue. This ED provided care similar to what is recommended by the AAP in this initiative, in that Zofran was ordered.

The requested health service/treatment of an inpatient admission was not medically necessary for this patient. An alternate level of care would have been appropriate, secondary to the patient's poor weight gain coupled with dehydration.