Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder/Seizures
Treatment: Inpatient Hospital
The health plan denied the requested inpatient stay. 
The health plan's determination is overturned.

The patient is a female teen with a medical history significant for migraines and anxiety who presented with nausea, multiple episodes of vomiting, diarrhea, and an episode of loss of consciousness with seizure activity and a post-ictal period. Vital signs included a blood pressure of 127/21 millimeters of mercury (mmHg), a heart rate of 96 beats per minute (bpm), and a respiratory rate of 22/minute. She was cold and a temperature was not obtainable. An examination was significant for non-toxic appearance, moist mucous membranes, no abdominal tenderness, brisk capillary refill, a Glasgow Coma Scale (GCS) of 15, and no focal deficits. While in the emergency department (ED), she had recurrent retching and multiple episodes of vomiting. She was able to ambulate to the bathroom. Laboratory evaluation was significant for a venous potential hydrogen (pH) of 7.4, an elevated lactate of 3.2, an elevated white blood cell (WBC) count of 19.3K (thousand), mild hypokalemia of 3.4, hyperglycemia of 156, and metabolic acidosis with a carbon dioxide (CO2) of 19. Rapid influenza and COVID (coronavirus disease)   testing were negative. A head computed tomography (CT) was obtained and was unremarkable. She continued to have vomiting despite 8 mg (milligrams) of Zofran, so she was treated with 2 mg of Ativan. She was treated with two saline boluses followed by maintenance intravenous (IV) fluids. During sleep she was hypoxic to 78% (percent) in room air, necessitating supplementary oxygen via nasal cannula. She was admitted for further management. Her hospital stay was complicated by double vision, with sluggish left eye reaction on exam, prompting an ophthalmology evaluation (no abnormalities on fundoscopic exam) and a CT angiogram (no abnormalities). A routine electroencephalogram (EEG) was done and was unremarkable. Diplopia resolved by hospital day two. She had no further diarrhea or vomiting once arriving to the pediatric floor. Neurology was also involved in her management. She was ultimately deemed stable for discharge with neurology and ophthalmology follow-up and a video EEG.

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

The requested acute inpatient admission was medically necessary for this young woman who presented with vomiting, dehydration, seizure activity, hypotension, and eventual double vision. She could not have been safely managed at a lower 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. Vomiting limits the success of oral rehydration, prompting use of anti-emetic medications. 
This young woman presented with vomiting and seizure activity. Evaluation revealed leukocytosis and metabolic acidosis consistent with significant dehydration. She responded well to fluids and was able to advance her diet. She developed diplopia and required supplemental oxygen while sleeping. Her work-up expanded to include plans for a video EEG, and neurology and ophthalmology consultations. She was hypotensive and tachycardic throughout her hospital stay. Given the complex nature of her illness, an acute inpatient admission was medically necessary and appropriate. A lower level of care would not have been appropriate in this case.