Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute gastroenteritis
Treatment is an inpatient admission 
The insurer denied coverage for the inpatient admission.
The denial is upheld.

The patient with a benign past medical history, presented to the Emergency Department (ED) for assessment and management of one episode of non-bilious, non-bloody vomiting 2 days prior to admission, followed by diarrhea x 2 days, tactile fever, decreased oral intake and decreased activity. There was no associated GI (gastrointestinal) bleeding, known weight loss, lethargy, sick contacts or dysuria. The patient's vitals on arrival were notable for Heart Rate 150, Temperature 100.7 F (Fahrenheit), Respiratory Rate 24 and room air oxygen saturation of 98%. Admitting weight was 13.6 kilograms. 

Physical exam showed a well-appearing, active male in no apparent distress. He appeared non-toxic and was making tears. He had a dry throat with normal capillary refill and skin turgor. Lungs were clear with normal effort. Cardiac exam was unremarkable. Abdomen exam was soft. There was no associated pain, organomegaly, distension, rebound, guarding or masses. There was no rectal exam reported. Admitting laboratories were notable for sodium 135, potassium 3.8, bicarbonate 12, BUNM (blood urea nitrogen) 12, creatinine 0.4, glucose 56, calcium 9.8, white blood cell 8.1 with 66% neutrophils, hemoglobin 11.4, platelet 309, albumin 4.1, bilirubin 0.5, AST (Aspartate transferase) 47, ALT (alanine transaminase)12, and AP (alkaline phosphatase) 156. No lipase, amylase or lactate were performed. No urinalysis was submitted for review. 

Nasal viral washings were negative for RSV (Respiratory Syncytial Virus), COVID-19 (coronavirus disease) and Influenza A/B. No imaging was performed. He received one 280cc (cubic centimeters) IV (intravenous) bolus of normal saline followed by D (dextrose) 5 normal saline at 70 cc/hour. In addition, he received one dose of Zofran 2mg (milligrams) IV push and oral Tylenol. He was noted to tolerate breast feeding well while in the Emergency Department.

This child appears to have had a viral gastroenteritis (self-limited vomiting that resolved before presentation followed by loose stools) and mild dehydration that resolved by the time of admission to the inpatient setting. He did not appear significantly dehydrated on presentation (dry throat, making tears) that improved with modest fluid resuscitation. He demonstrated the ability to tolerate oral rehydration when offered prior to the decision to admit (breast feeding in the Emergency Department). 
 
A reason given to justify the inpatient setting was significant dehydration. In regard to volume status in a second review of dehydration in children from UpToDate the following elements summarize the assessment of the degree of dehydration: Degree of dehydration - Fluid repletion guidelines for children with gastroenteritis by the American Academy of Pediatrics, Centers for Disease Control, and the World Health Organization are based upon the degree of volume depletion. As a result, it is important to be as accurate as possible when assessing the degree of dehydration. Severe hypovolemia requires rapid isotonic fluid resuscitation, although oral rehydration may be sufficient for mild to moderate hypovolemia.

The documentation of this child's appearance and vitals would indicate minimal to mild dehydration on presentation that resolved with modest intravenous resuscitation administered 5 hours after his arrival. His laboratory abnormalities were not critical and would be expected to correct with fluid resuscitation followed by oral rehydration therapy. 

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 inpatient admission is not substantiated.