Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Viral gastroenteritis, hypoglycemia and dehydration

Treatment: Inpatient level of care

The insurer denied coverage for inpatient level of care

The denial is upheld

This is the case of a male with a past medical history notable for a recent ruptured ear drum that presented to the Emergency Department (ED) by ambulance for assessment and management of 3-4 days of watery, non-blood stools and non-bloody, non-bilious vomiting for 1-2 days. His mother notes decreased oral intake, fatigue, crying without tears and sick contacts at home. There was no associated fever, upper respiratory infection (URI) symptoms, rashes, distention, low urine output or weight loss. The patient's vitals on arrival were notable for heart rate (HR) 121 Temperature 99.5 Fahrenheit (F), respiratory rate (RR) 20-24 and room air oxygen saturation of 100%. Admitting weight was 8.5 kilograms and height was 80 centimeters. Physical exam showed an awake and alert male. He appeared pale with low energy. He had moist mucus membranes with normal capillary refill and normal skin turgor. Lungs were clear with normal effort. Cardiac exam was unremarkable. Abdomen exam was soft with normal bowels sounds. There was no associated tenderness, guarding, organomegaly, distension, rebound, or masses. He had a diaper rash. He was given an oral challenge and tolerated pretzels and some fluids. He had additional watery stools while in the ED. He was admitted to the inpatient service for observation and continued hydration with diagnoses of viral gastroenteritis, hypoglycemia and dehydration. His vitals were notable for HR 133 Temp 99 F, RR 24 and blood pressure (BP) 110/70. No vomiting was documented during the admission. He was permitted a regular diet since admission that he tolerated well. IV fluids were decreased gradually. Repeat laboratories were notable for sodium 141, potassium 3.2, bicarbonate 25, creatinine 0.2 and glucose 85. He remained afebrile throughout the admission. He was discharge home for outpatient follow-up. No additional treatment was given. 
   
The most useful clinical signs that predicted 5 percent hypovolemia in children were delayed capillary refill time, reduced skin turgor, and deep respirations with or without an increase in absolute respiratory rate. A combination of signs and symptoms was better than an individual finding at predicting hypovolemia.

-	Severe dehydration (>=10 percent volume loss) - Such children typically have a near-shock presentation as manifested by hypotension, decreased peripheral perfusion with a capillary refill of greater than three seconds, cool and mottled extremities, lethargy, and deep respirations with an increase in rate. Severe hypovolemia requires immediate aggressive isotonic fluid resuscitation to restore the effective circulating volume (ECV) and prevent ischemic tissue injury.
 
The documentation of this child's appearance and vitals would indicate mild dehydration that resolved by the time of the decision to admit to the hospital. A venous lactate of 2 is insufficient to estimate his volume status. His hypoglycemia resolved with supplementation. After bolus fluid resuscitation in the ED, anti-emetics and observation the child could have avoided an unnecessary acute care admission. Zofran was the key to his tolerance of fluids as he tolerated oral pretzels and fluids in the ED and a regular diet after admission. After a brief period of observation this patient could have been safely discharged with outpatient follow-up. He received no acute care after admission to merit reimbursement at that level except for continued IV fluids despite tolerating feeds without issue once permitted. In regards to the acute inpatient admission the determination by the carrier that the admission was not medically necessary was correctly applied, objective, clinical valid, compatible with established principles of health care and flexible enough to permit justified variation. This decision was rendered based on review of the hospital record and the reviews from UpToDate summarizing the approach to nausea/vomiting and dehydration in children in cited above.

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

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