Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroesophageal reflux.

Treatment: Inpatient admission.

The insurer denied coverage for the inpatient admission.

The denial is upheld. 

This patient is a female child with a past medical history notable for neonatal hypoglycemia (maternal gestational diabetes) who was brought to the Emergency Department (ED) for evaluation of a choking episode with nasal regurgitation of formula associated with facial cyanosis lasting seconds responsive to suctioning.  The patient was seen at the pediatrician's office and was diagnosed clinically with gastroesophageal reflux.  The patient's parents were reassured and counseled regarding reflux precautions.  There was no fever, sick contacts, weight loss or bleeding.  The child was fed Sim Neosure 4 ounces every 3 hours.  The patient's vital signs on arrival were notable for: Heart Rate 164, Temperature 98.1, Respiratory Rate 44, and Blood Pressure 86/52 and Oxygen Saturation of 100% on room air.  The patient's admitting weight was 4.56 kilograms.  The patient's physical exam showed an awake, well-nourished, well-appearing child in no acute distress. The decision to admit the patient for observation occurred before any evaluation was performed.  An intravenous (IV) catheter was inserted and lab work was sent.  Admitting lab findings were notable for negative nasal pharyngeal swab for influenza A/B/respiratory syncytial virus (RSV) and COVID; sodium 138, potassium 6.2, blood urea nitrogen (BUN) 14, creatinine 0.34, chloride 104, bicarbonate 23, glucose 69, white blood cell (WBC) count 9.5 without a left shift (neutrophils 24%, no bands), hemoglobin 11.8 and platelets 440.  No imaging was performed.  No urinalysis was submitted for review. The patient's electrocardiogram (EKG) was normal for age.  The patient continued to feed without any repeat episodes or abnormalities seen on telemetry or pulse oximetry.  The patient remained afebrile.  No other diagnostic testing was performed.  The patient was counseled regarding gastroesophageal reflux precautions and was discharged home for outpatient follow-up.
 
Based on the review of the medical record, acute inpatient admission was not medically necessary for this patient. This patient appeared to have had an episode of gastroesophageal reflux with laryngospasm. The patient's physical exam was unremarkable and this patient's vital signs, nasopharyngeal cultures, laboratories and EKG after the decision to admit the patient, were all reassuring.  The treating team suspected gastroesophageal reflux but chose to treat the episode as a brief resolved unexplained event (BRUE).  In a review of the BRUE from UpToDate, this patient did not meet criteria for low-risk BRUE.

In regards to likely cause of this patient's presentation in a second review of gastroesophageal reflux (GER) in children from UpToDate, this patient met the criteria for GER. The evaluation performed in the ED after the decision to admit the patient could have been followed by short-term observation and discharge home with GER precautions or acid suppressing medications.  There were no red flags in this case other than the frustration of the patient's mother that nothing was being done to address these episodes.  The hospitalization did not add to the understanding of this patient's conditions and the patient left with the same recommendations already imparted by the pediatrician.  Given this presentation, the literature would support an initial assessment and a brief period of observation and monitoring before outpatient follow-up.  

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.
 
The carrier's denial of coverage for the inpatient admission should be upheld.  The medical necessity is not substantiated.