Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute viral gastroenteritis

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial is upheld. 

This patient is a female with a past medical history notable for asthma, eczema, sickle trait and nut allergy that presented to Emergency Department (ED)  for the assessment and management of non-bloody, non-bilious vomiting x 1 day (10 episodes) and burning epigastric abdominal discomfort. The vomiting started after eating French fries that evening with no other family members affected. There was no associated bleeding, weight loss or change in activity. The patient's vitals on arrival were notable for heart rate 147, temperature 36.9 C, respiratory rate 22, blood pressure 117/73 and room air oxygen saturation of 98%. The patient's admitting weight was 37.2 kilograms. On physical exam, the patient was noted to be well-developed, well-nourished female in no apparent distress. The patient had moist mucus membranes, and her skin turgor and capillary refill were within normal limits. The patient's lungs were clear, and the patient's cardiac exam was unremarkable. The patient did not vomit after admission, had no pain and received no additional medications. The patient's intravenous fluids were stopped. There were no repeat laboratories performed. The patient was discharged home for outpatient follow-up. The patient's heart rate at discharge was 104.

Based on the review of the medical record, the patient appeared to have an acute viral gastroenteritis with self-limited vomiting and minimal dehydration that responded to modest intravenous repletion. The patient's physical exam, laboratories and vitals were for the most part unremarkable (heart rate was elevated on presentation). According to the UpToDate review on the approach to nausea and vomiting in children, 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. In this case, the patient did not meet any of these clinical conditions to warrant the need for inpatient management. The patient's intervention in the ED did not meet the criteria of failing outpatient management. The patient was given a single dose of Zofran and no fluid boluses.

According to UpToDate review on dehydration in children, a number of findings on physical examination coupled with the pertinent clinical history are used to help assess the severity of the patient's hypovolemia. These findings include the patient's pulse, blood pressure, and skin turgor, and systemic signs such as increased thirst or lethargy, and changes in urine output. The most useful clinical signs that predicted 5 percent (mild) hypovolemia in children were delayed capillary refill time, reduced skin turgor, and deep respirations with or without an increase in absolute respiratory rate. After a brief period of observation and monitoring, this patient could have been safely discharged home with outpatient follow-up. Thus, inpatient admission was not medically necessary to treat this patient's medical condition.

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 hospital admission is upheld. The medical necessity is not substantiated.