Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal/Other/Diarrhea.
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a male child with a medical history significant for two prior hospitalizations for diarrhea who presented to the emergency department (ED) with a ten-day history of diarrhea, vomiting at the beginning of the illness, a fever to 103F., decreased intake, and decreased urine output. He had nine episodes the day he presented. Vital signs included temperature of 36.7C., a heart rate of 131 beats per minute (bpm), and a respiratory rate of 32/minute. An examination was significant for the child being active, moist mucous membranes, a benign abdomen and non-focal neurologic exam. Laboratory evaluation revealed a white blood cell (WBC) count of 17.3K, and a carbon dioxide (CO2) of 18. He was treated with a normal saline bolus followed by maintenance intravenous (IV) fluids. The patient was admitted for management of ongoing loose stools and dehydration. A repeat CO2 after fluids improved to 23. COVID19, respiratory syncytial virus (RSV), and influenza were negative. A urinalysis was negative for signs of infection. Stool studies revealed the presence of EAEC (E coli), EPEC (E coli), and norovirus. Admission orders included maintenance IV fluids, consideration for fluid replacement for stool losses, anti-pyretic, and follow-up blood cultures. Per the attending note, the two E coli variants were considered incidental normal flora. He continued to have watery diarrhea overnight and was not drinking the Pedialyte. His mother was concerned he was having abdominal pain. He was started on the acute gastroenteritis inpatient pathway and an admission kit was provided to the mother. The patient remained on IV fluids and anti-pyretics. He had three episodes of diarrhea overnight but was taking fluids by mouth and was not having abdominal discomfort. His stool was becoming more formed and he was making wet diapers. The patient was deemed stable for discharge home.
At issue is the medical necessity for the inpatient stay.

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

No. The patient could have been safely managed at an alternate level of care.
Acute gastroenteritis is a major problem worldwide, representing one of the leading causes of morbidity and mortality in children. There are an estimated 2.5 million deaths each year attributable to gastroenteritis in children under the age of 5 years. Most cases are caused by viruses, are self-limited, and require supportive treatment. According to the World Health Organization, oral rehydration therapy is the treatment of choice, particularly where diarrhea is the prominent feature and dehydration is mild to moderate. Intravenous rehydration is indicated when oral rehydration fails or when output is excessive. Output (vomiting, diarrhea) limits the success of oral rehydration, prompting use of anti-emetic medications. According to current guidelines for evaluation and management of acute diarrheal illness, people with fevers or bloody diarrhea, as well as severe cramping or signs of sepsis, should undergo diagnostic studies to determine if antimicrobial agents are appropriate. Additional testing such as blood cultures may also be indicated.
In the case of this male child, he was having copious amounts of loose stool and decreased oral intake. He was not able to keep up with his stool losses and had become dehydrated. Because of the ongoing loose stool and poor intake, it was reasonable and medically necessary to monitor him in the hospital. However, he was hemodynamically stable with no evidence of impending hypovolemic shock or sepsis, no serious electrolyte disturbances, and no bloody stool. He did not require acute inpatient admission and could have been safely managed at an alternate level of care.