Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting
Treatment: Inpatient admission
The insurer denied the inpatient admission.  
The denial is upheld.

The Inpatient admission was not medically necessary.

The patient is a female infant. She presented to the ED for evaluation of 19 episodes of vomiting over two days. She was voiding and passing stool without diarrhea. 

The patient had no fevers or respiratory symptoms. Vital signs included temperature 37.2, heart rate 129, respiratory rate 30, and 100% oxygen saturation in room air. Examination was significant for no acute distress, well-hydrated appearance, moist mucous membranes, regular heart rate and rhythm clear lungs, benign abdomen, and non-focal neurologic exam. There was concern for possible hypertrophic pyloric stenosis. 

The patient continued to vomit while in the ED. An intravenous (IV) line was placed and she was given IV fluids. Metabolic panel was significant for hyperkalemia with potassium 7.1 (noted later to be due to hemolysis). Ultrasound was not available until the following day. She was admitted for further management. 

The patient was treated with a normal saline bolus, after which her potassium decreased to 5.5. Admission orders included nothing by mouth, IV fluids at maintenance, abdominal ultrasound and consideration for surgical consultation if positive for pyloric stenosis. 

Overnight, the patient had no further episodes of vomiting. The abdominal ultrasound revealed a sonographically prominent pylorus, but the dimensions were within normal limits. Urine was collected to rule out urinary tract infection and was negative (the initial clean catch sample was suspect, so a catheterized specimen was obtained). She was able to tolerate advancing feedings without vomiting. 

The patient was subsequently deemed stable for discharge to follow-up with her pediatrician in two days. 

Pyloric stenosis occurs in about one in 1000 infants in the United States. It is more common in white infants of northern European ancestry, least common in the Asian population. Males are much more likely to be affected than females, and there is higher risk if the mother has history of pyloric stenosis. The initial presentation of pyloric stenosis is non-bilious emesis. It is not always projectile, but is typically progressive. Infants with pyloric stenosis remain hungry, even after vomiting. 

The classic physical exam finding is a palpable "olive" in the right upper quadrant, and there may be a visible peristaltic wave after feeding. Ultrasound is 95% sensitive in diagnosis pyloric stenosis. Contrast studies may also be diagnostic. The initial treatment goals include correction of any electrolyte abnormalities (e.g., metabolic alkalosis) and fluid resuscitation to correct dehydration. Surgical intervention involves pyloromyotomy. Post-operatively, feedings can usually be started after 12-24 hours, and advanced to full feedings by 48 hours. Surgical treatment is curative, and it has a low associated operative mortality of less than 0.5%.

This infant presented to the ED with numerous episodes of vomiting over the course of 24 hours. It was non-bilious, not projectile, and not associated with feedings. Because of concerns for pyloric stenosis (and inability to get an abdominal ultrasound until the next day), she was admitted for further management. While it was reasonable to observe the infant pending diagnostic imaging, she was overall hemodynamically stable without signs of sepsis or significant dehydration. She did not require acute inpatient admission, and she could have been safely managed at a lower level of care, such as observation.