Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dehydration status post tonsillectomy and adenoidectomy.
Treatment: Inpatient admission.

The insurer denied: Inpatient admission.  The denial is upheld.

The patient is a teenage female with medical history significant for chronic tonsillitis status post tonsillectomy and adenoidectomy. She presented to the emergency department with vomiting and epigastric pain. The vomit was described as blood-streaked, and the pain was non-radiating and was rated 7/10. She was unable to eat much or talk since the surgery, due to sore throat. The patient's vital signs included temperature 36.6, heart rate 93, respiratory rate 20, and blood pressure 120/88. Examination was significant for lethargic and dehydrated appearance, spitting saliva with admixed blood, posterior oropharyngeal erythema, dry lips, moist mucous membranes, white plaque at the back of the throat at site of removed tonsils, tachycardia, epigastric abdominal tenderness, brisk capillary refill, and non-focal neurologic exam. She had one episode of vomiting in the emergency department described as non-bloody and yellow stomach contents. The patient's suspected diagnoses included dehydration with tachycardia and gastritis with epigastric pain post-tonsillectomy. Orders included intravenous fluids, screening labs, anti-emetic medication, and ear/nose/throat (ENT) consultation. Bedside glucose was 117. 
Laboratory evaluation was significant for venous pH 7.34 with HCO3 (bicarbonate) 20.1 consistent with dehydration and not eating, PT (prothrombin time) 14.8 with INR (international normalized ratio) 1.32, PTT (partial thromboplastin time) 44.2, WBC (white blood count) 13.9K (thousand) with 80.3% neutrophils, platelets 525K (thousand), hemoglobin 14.8 likely hemoconcentrated, CO2 (carbon dioxide) 20, glucose 95, BUN (blood urea nitrogen) 23 with creatinine 0.9 consistent with prerenal azotemia secondary to dehydration, betahydroxybutyrate 3.35, and lipase 189. The patient was treated with famotidine, normal saline bolus, magic mouthwash swish and spit, and Decadron and admitted for further management. Ear/nose/throat evaluation indicated expected post-operative findings. Pediatric consultation was also requested with recommendations for Unasyn for 24 hours, continued intravenous fluids, Tylenol as needed, and ice chips and Pedialyte on demand. Admission orders included maintenance intravenous fluids, nothing by mouth except ice chips, famotidine, and Tylenol/Motrin as needed. She remained hemodynamically stable and was treated with Unasyn for 24 hours. She was eventually able to tolerate soft foods and discontinue intravenous fluids. She was subsequently deemed stable for discharge on day #4.

The Inpatient admission was not medically necessary.

The patient could have been safely managed at lower level of care. In this patient's case, she presented with vomiting and epigastric pain. She was clinically dehydrated, with ongoing vomiting in the ED (emergency department). She was not actively bleeding, and on ENT (otolaryngology) evaluation, the surgical bed demonstrated expected post-operative findings. While it was reasonable to monitor her overnight for resolution of vomiting and ability to tolerate adequate fluids, she was overall hemodynamically stable with no evidence of hemorrhage and no evidence of post-operative infection. She did not require acute inpatient admission and could have been safely managed at lower level of care. This is consistent with current standards of care.