Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rhinovirus. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

The patient was a toddler with a benign past medical history that presented to the Emergency Department for assessment and management of intermittent non-bilious, non-bloody vomiting x 2-3 days, irritability and fever. Of note was that the patient had been seen the same day at Urgent Care and was negative for Covid, Influenza A/B and strep (streptococcus). The patient had one loose stool noted. There was no associated gastrointestinal (GI) bleeding, rashes, sick contacts, weight loss or dysuria. The patient's initial vitals were notable for HR (heart rate) 144, Temperature 99.6 degrees Fahrenheit that later rose to 102.4, respiratory rate 20, blood Pressure of 117/79 and room air oxygen saturation of 98 percent (%). Physical exam showed an awake and alert toddler in no apparent distress. She had dry lips and dry mucus membranes. She was irritable but consolable. She had normal capillary refill. Her lungs were clear with normal effort. The cardiac exam was unremarkable. Her abdomen exam was soft. There was no associated pain, organomegaly, distension, rebound, guarding or masses. There was no rectal exam reported. Laboratories were notable for sodium 138, potassium 4.8, bicarbonate 21, blood urea nitrogen (BUN) 11, creatinine 0.4, glucose 74, white blood cell 9.8 without a left shift (neutrophils 52%, no bands), hemoglobin 10.2, platelets 219 and an unremarkable liver panel. The respiratory pathogen panel was positive for rhino/enterovirus. A urinalysis was notable for specific gravity 1.027, pH (potential for hydrogen) 5.5 and dip positive for trace protein, ketones and moderate blood but negative for nitrates and leukoesterase. 

 
This child appeared to have a rhino/enterovirus upper respiratory infection leading to self-limited vomiting and mild dehydration. Although intake was overall decreased, she continued to tolerate fluids after Zofran was administered x 1 dose. In accordance with a review of the approach to nausea and vomiting in infants and children from UpToDate 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. She did not meet any of these criteria to merit the inpatient setting. Certainly, her vomiting after an oral medication did not constitute a failed oral intake trial. 
 
The documentation of this child's appearance and vitals would indicate mild to moderate dehydration on presentation that resolved with modest resuscitation with a single 20cc (cubic centimeters)/kg (kilogram) normal saline bolus. After a single dose of Zofran her vomiting ceased, and she could have been hydrated intravenously for a short period to clear ketones and then converted to oral rehydration therapy as per standard of care avoiding the short inpatient stay. Continued intravenous fluids when vomiting had abated and was not clinically needed as oral rehydration would have sufficed. She received no acute care after admission to merit reimbursement at that level. There was no indication for intravenous Pepcid that could have been given orally, if needed at all. She appeared to be admitted and her oral intake was observed while receiving modest intravenous fluids that improved after dropping her fluid infusion rate. 

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 full hospital admission is not substantiated.