Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dehydration

Treatment: Inpatient hospital stay

The insurer denied coverage for inpatient hospital stay

The denial is overturned. 

The patient was a male infant brought to the emergency room (ER) who had been born prematurely at 32 weeks. The weight was about 4.2 kg. The infant had a several day history of vomiting, and had been to another ER days before. In the ER, vomiting continued, and a trial of oral feeds failed. An intravenous (IV) was started, and a bolus of fluid with 20 ml/kg was initiated. The patient was then admitted. The infant had normal electrolytes, no pyloric stenosis on ultrasound, normal chest x-ray, but had viral infection with rhinovirus and/enterovirus. The infant gradually improved, and was able to drink well, so he was discharged.

The patient is a small infant who had been born prematurely. This puts the infant at significant risk of dehydration and rapid deterioration from dehydration or even pulmonary issues due to the rhinovirus. The patient was unable to tolerate oral feeds even in the ER, so admission was a sound medical judgement, and he received appropriate care.      

The inpatient hospital admission is considered medically necessary for this patient.

This was a small infant so the patient is at risk for rapid deterioration until stabilized. The family had failed outpatient management since vomiting continued, diarrhea occurred and oral intake had declined. The patient was diagnosed with rhinovirus and enterovirus. Formal inpatient admission was indicated because the vomiting had been persistent for days, the infant was clinically dehydrated and needed significant IV fluid resuscitation that included an initial fluid bolus of 20 ml/kg.

Several studies showed that clinical assessment can be inaccurate when assessing infant dehydration, so the history is very important. In this case, the vomiting was persistent for days and there was failure to improve at home, and oral intake was decreased.

"Infants and young children are particularly susceptible to diarrheal disease and dehydration. Reason include higher metabolic rate, inability to communicate their needs or hydrate themselves, and increased insensible losses. Other causes of dehydration may be the result of other disease processes resulting in fluid loss which includes: diabetic ketoacidosis (DKA), diabetes insipidus, burns, excessive sweating, and third spacing. Dehydration may also be the result of decreased intake along with ongoing losses. In addition to total body water losses, electrolyte abnormalities may exist. Infants and children have higher metabolic needs and that make them more susceptible to dehydration. Dehydration is a major cause of morbidity and mortality in infants and young children worldwide. Each year approximately 760,000 children of diarrheal disease worldwide. Most cases of dehydration in children are the consequence of acute gastroenteritis. Acute gastroenteritis in the United States is usually infectious in etiology. Viral infections, including rotavirus, norovirus, and enteroviruses cause 75 to 90 percent of infectious diarrhea cases." (Vega et al 2020)

"The assessment of the severity of dehydration is essential, as therapy instituted should be based on its severity. However, this assessment of the extent of volume depletion may be difficult. It is difficult to accurately distinguish varying degrees of dehydration based on clinical examination alone. For example, infants and young children with mild dehydration may present with either minimal or no clinical findings other than reduced urine output. Also, children with moderate dehydration manifest with dry mucous membranes, decreased skin turgor, tachycardia with a prolonged capillary refill, and abnormal respiratory pattern." (Kight et al 2021)

The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient in the denial of the inpatient admission.

The insurer's denial of coverage for the inpatient hospital admission is overturned.  The medical necessity is substantiated.