Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrointestinal/gastroenteritis
Treatment: Inpatient hospital stay
The health plan's determination is upheld in whole. Inpatient stay was not medically necessary.

This is a pediatric patient who presented with upper respiratory infection (URI), vomiting and watery diarrhea for 2 days. Patient had a  temperature  of 102 on the day prior but resolved with Motrin. Patient with decreased by mouth (PO) intake and no urine output for the past 24 hours. No sick contacts at home. No history of eating anything outside of the home. Patient has vomited 8-10 times since the day prior and reportedly could not keep anything down and had diarrhea 2-3 times since the day prior. Stool described as watery and sometimes yellowish. Mucous membranes were dry. Tachycardia present. 
At the time patient was admitted the illness was thought to be due to a viral infection. The suspected course of  illness would not be expected to span greater than 2 midnights. Care involved intravenous fluids (IVF) and Zofran which can be given as an orally disintegrating tablet (ODT) and does not necessarily have to be administered IV or IM. Patient was in the ER for 2 hours at the time the decision was made to admit. Patient was deemed to have failed IM Zofran 32 minutes after it was administered and did not require any highly skilled or technical care during  stay. Patient did not meet criteria for inpatient level of care as the patient did not demonstrate persistent inability to maintain oral hydration after ER treatment and observation level of care. Patient responded well to ER resuscitation of a normal saline bolus followed by 1 maintenance IVF. ER exam documented dry mucous membranes but by the time the patient  was admitted and had received a normal saline bolus, the exam was normal. This patient was not given an adequate amount of time to respond to emergency room treatment. This patient could have been treated at a lower level of care. At the time of admission patient did not have absent tears, delayed capillary refill, lethargy or dry mucous membranes. There is no mention of the patient vomiting after admission to the hospital. Patient did not have any abnormal lab results apart from a low glucose level that quickly returned to normal within 1 hour. There is no documentation of further glucose levels checked after admission. Patient rapidly improved and was discharged within 24 hours of  arrival. Oral rehydration therapy is the recommended first line for mild to moderate dehydration. Patient did not meet currently accepted criteria for admission to the hospital for dehydration. Current criteria for admission include:
Caregivers cannot provide adequate care at home; Substantial difficulties exist in administrating ORT, including intractable vomiting, ORS refusal, or inadequate ORS intake; Concern exists for other possible illnesses complicating the clinical course; ORS treatment fails, including worsening diarrhea or dehydration despite adequate volumes;
Severe dehydration (>9% of body weight) exists; Social or logistical concerns exist that might prevent return evaluation, if necessary.
Factors as young age, unusual irritability or drowsiness, progressive course of symptoms, or uncertainty of diagnosis exist that might indicate a need for close observation.
Given the fact that this patient did not meet any of these clinical criteria based on the information documented in her chart, an inpatient stay was not medically necessary for this patient.