Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intractable Vomiting 
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission
The denial is upheld 

The patient is a toddler with a past medical history of intermittent vomiting, hypoglycemia, feeding problems and poor growth that presented to the Emergency Department for assessment and management of intermittent non-bilious, non-bloody vomiting for 1 day. Of note, the patient had been admitted twice with similar symptoms at another institution and was undergoing outpatient assessment by both gastroenterology and endocrinology. There was no associated fever, gastrointestinal (GI) bleeding, diarrhea, weight loss or dysuria. The patient's initial vitals were notable for Heart Rate (HR) 133, Temperature (T) 97.7 degrees Fahrenheit (F) Respiratory Rate (RR) 27, and room air oxygen saturation of 98 percent. Laboratories were notable for sodium 138, potassium 4.4, bicarbonate 14, blood urea nitrogen (BUN) 24, creatinine 0.3, glucose 41, white blood cells 18.7 with a left shift (neutrophils 83% (percent), no bands), hemoglobin 11.9 and platelets 372. A rapid Covid test was negative. No urinalysis was submitted for review. The toddler was given Zofran 2 mg (milligrams) intravenous push (IVP) one time, juice and intravenous fluids dextrose (D) 25% in water / 2 cubic centimeters per kilogram (D25W 2cc/kg). Repeat glucose was 194 and the patient was clinically better. No antibiotics were administered. The patient was transferred to this hospital for assessment and admission. Physical exam showed an awake and alert toddler in no apparent distress. Dry lips and dry mucus membranes were observed. Lungs were clear with normal effort. Cardiac exam was unremarkable. Abdomen exam was soft. There was no associated pain, organomegaly, distension, rebound, guarding or masses. The patient was started on dextrose (D) 5% in normal saline + potassium at 39cc/hour later increased to 58cc/hour. No imaging was performed. No additional medications were administered. Repeat laboratories were notable for sodium 140, potassium 4.1, bicarbonate 22, BUN 6, creatinine 0.5, glucose 82, albumin 3.9, aspartate aminotransferase (AST) 39, alanine transaminase (ALT) 14 and alkaline phosphatase (ALP) 222. A gastroenterology consult was obtained that concluded that either cyclic vomiting or a metabolic issue may exist. The patient continued to receive intravenous fluids despite tolerating oral liquids. The patient was afebrile throughout the admission and never vomited since admission. The patient never had pain and no additional anti-nausea agents were administered. The patient was discharged home for outpatient follow-up; heart rate varied between 127 - 101 and was 106 at discharge.
 
In accordance with a review of the reasons to admit such an individual  it would include signs of significant dehydration poorly responsive to intravenous hydration in the Emergency Department, significant weight loss, profound lethargy, hemodynamic instability, significant electrolyte imbalance, demonstrated oral hydration intolerance to oral challenge, 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. The patient did not meet any of these criteria to merit the inpatient setting. Certainly, the vomiting was not intractable and had resolved before arriving at the admitting hospital.
 
Based on the above, the insurer's denial must be upheld.   The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for acute inpatient care is not substantiated.