Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastritis.

Treatment: Inpatient Admission.

The insurer denied the inpatient admission.

The denial was upheld.

This is a female infant patient who presented to the Emergency Department (ED) with non-bloody, non-bilious vomiting, non-bloody diarrhea with nasal congestion for several days. It was reported that the patient had been pulling her ears. The patient's vital signs on arrival were notable for a heart rate of 162, a temperature of 97.4F, a respiratory rate of 38, a blood pressure of 111/83 and a room air oxygen saturation of 95%. The admitting weight was 9.5 kilograms with a height of 74.9 centimeters. A physical exam was performed that revealed the patient to be well-developed, well-nourished in no apparent distress. She had moist mucus membranes and clear nasal discharge. Tympanic membranes were partially obscured by cerumen. Lungs were clear. Cardiac exam was unremarkable. Abdomen exam was soft with normal bowel sounds. Admitting laboratories were notable for a white blood cell count of 15.5 without a left shift (33% neutrophils), hemoglobin of 12.3 and platelets of 463. A rapid strep test, influenza assay and respiratory syncytial virus (RSV) assay were performed with negative results. A chest x-ray was done and noted to be unremarkable. She had been treated with a single dose of Zofran at the Pediatrician's office earlier the same day. Multiple attempts for intravenous (IV) access were made and were unsuccessful; therefore no IV fluids or medications were administered. Pedialyte was given to the patient but she vomited it. The decision was made to transfer her to another medical facility for further treatment. While awaiting transfer the patient was given Pedialyte without any vomiting. The patient continued to self hydrate successfully. The patient was medically stabilized and discharged home.

The insurer is denying the acute inpatient admission as not meeting medical necessity criteria as per MCG for Gastroenteritis, Dehydration or Dysentery, Pediatric ORG: P-190 (ISC). The hospital is appealing. The issue at hand is whether the acute inpatient admission was medically necessary.

In accordance with a review of the approach to nausea and vomiting in 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, hemodynamic instability, significant electrolyte imbalance, demonstrated oral hydration intolerance to oral challenge (after treatment with anti-emetics and fluids), 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. She had no interventions to address her vomiting to merit "failed outpatient management."  (no fluids were administered and a single dose of Zofran was given at the Pediatrician's office and not repeated).

In regards to her 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.

Volume depletion is most objectively measured as a change in weight from baseline. Acute loss of body weight reflects the loss of fluid, not lean body mass; thus, a 2 kg weight loss should reflect the loss of two liters of fluid.

In most cases, however, a previous recent weight is not available. As a result, a number of findings on physical examination coupled with the pertinent clinical history are used to help assess the severity of hypovolemia. These findings include the child's pulse, blood pressure, skin turgor, systemic signs such as increased thirst or lethargy, and changes in urine output.

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.

After a brief period of observation and monitoring, this patient could have been safely discharged with outpatient follow-up. She actually received no acute care after presentation/admission to merit reimbursement at that level. The insurer acted reasonably, with sound medical judgement, and in the patient's best interest. 

Based on the above, the medical necessity for the acute inpatient stay is not substantiated. The insurer's denial is upheld.