Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive/Gastrointestinal/Vomiting.
Treatment: Full Hospital Admission.
The health plan denied the requested inpatient stay as not medically  necessary. 
The health plan's determination is upheld.

The patient is a boy with no significant past medical history, who was sent to the emergency department (ED) by his primary care physician (PCP) for fever, vomiting, diarrhea, anorexia and fatigue. In the ED, the patient was noted to have a delayed capillary refill and laboratory significant for glucose of 55, a calcium of 7.8, and a bicarbonate of 17. He was given an intravenous fluid bolus, Zofran, Tylenol and an oral challenge. His capillary refill improved after a bolus, however, only drank 1/3 of juice cup for his oral challenge. He was started on intravenous (IV) maintenance fluids and was admitted secondary to mild dehydration, hypoglycemia, hypomagnesemia and hypocalcemia.
As per the progress notes, the patient continued to have diarrhea (7 episodes) and his intravenous fluids were increased to 1.5 times maintenance. Overnight, his diarrhea improved, and his oral intake improved, and intravenous fluids were stopped. He was noted to have adequate urine output and only one episode of diarrhea on the day of discharge. Repeat laboratory showed improvement in the bicarbonate, glucose and calcium. The patient was discharged with PCP follow up in 1-2 days.
At issue is the medical necessity for the inpatient stay.

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

The American Academy of Pediatrics (AAP) published practice guidelines for the treatment of dehydration secondary to gastroenteritis that advocates for the use of oral rehydration therapy (ORT) over intravenous (IV) rehydration. In a Cochrane review involving 17 trials and 1811 children with acute gastroenteritis, it was demonstrated that ORT had equivalent success rates when compared with IV rehydration.
In 2020, the AAP performed a single-center quality improvement initiative between 2010 and 2016, where the investigators aimed to decrease the percentage of patients with gastroenteritis who were rehydrated with IV fluid. They implemented a dehydration evidence-based guideline (EBG) and concluded that it led to a decrease in frequency of IV administration, shorter lengths of stay, and lower health care costs.
Using the EBG provided in this initiative for this patient, it would have placed him under the moderate dehydration score. This ED provided care similar to what is recommended by the AAP in this initiative. After IV hydration repeat vitals, and exam showed improved capillary refill, and patient was given an oral challenge, which the ED felt this patient failed. According to the AAP EBG, it would be recommended to continue IV hydration for another 60 minutes after the initial bolus, and then attempt oral hydration. This was not attempted.
The treatment of gastroenteritis-related dehydration depends on the provider's ability to estimate the degree of dehydration. In a mild form of dehydration, it can be difficult to differentiate, and although several clinical dehydration scales have been developed to help guide clinical assessment, their validity and reliability have been studied with variable outcomes.

It was unclear from the medical records provided if this patient could not have continued to trial oral rehydration and electrolyte solutions at home, or continued care in the emergency department for his concerns of poor oral intake, as indicated by alternatives to admissions by the guidelines provided.

Therefore, with the MCG (Milliman Care Guidelines), coupled with the initiative described above, the requested health service/treatment of inpatient admission was not medically necessary for this patient. An alternative level of care would have been appropriate and the patient could have been safely discharged.