Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Gastroesophageal reflux

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

Patient is a young infant with a past medical history of non-bilious, non-bloody vomiting and arching minutes after feeds for the last 2 weeks. An outpatient abdominal sonogram showed no pyloric stenosis. Formula was changed. Because vomiting persisted and was occurring immediately after feeds, they presented to the Emergency Department (ED) for assessment. There was no associated fever, gastrointestinal (GI) bleeding, diarrhea, weight loss or dysuria. Physical exam showed an awake and alert infant in no apparent distress. The patient was fussy but consolable. He had moist mucus membranes and normal capillary refill. 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. There was no rectal exam reported. The patient was given a feeding while in the ED that he tolerated without vomiting. An abdominal/chest x-ray showed a mildly dilated stomach and small bowel loops with air seen in the rectum - considered to be non-specific. An electrocardiogram (EKG) was unremarkable. He was started on dextrose 5% (D5) in normal saline at 20 cubic centimeters (cc)/hour and admitted for intractable vomiting for an upper GI series to rule out malrotation and for a GI consult. No medications were administered prior to admission. His admitting weight was 4.8 kilograms. A second abdominal sonogram was performed that was again negative for pyloric stenosis. No upper gastrointestinal (UGI) series or GI consult were submitted for review. No repeat laboratories were sent. The baby was treated with oral Pepcid for presumed gastroesophageal reflux and formula was changed to Alimentum. The patient continued to tolerate a diet without vomiting and was discharged the following day for outpatient follow-up. 
 
This child appears to have feeding difficulties with vomiting likely secondary to gastroesophageal reflux and/or cow's milk protein intolerance. The arching with vomiting of only partial feeds was a clue that this was indeed reflux. In accordance with a review of the approach to nausea and vomiting in infants and children from UpToDate; the reasons to admit such an individual would include signs of significant dehydration poorly responsive to intravenous hydration in the ED, 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 infant did not meet any of these criteria to merit the inpatient setting. Certainly, a mild non-specific gas pattern on x-ray without associated abdominal pain or distention was not supportive of bowel obstruction/malrotation. The vomiting was not intractable and in fact never occurred throughout the short admission.
 
This infant suffered from gastroesophageal reflux. In a second review from UpToDate addressing gastroesophageal reflux in infants the authors noted symptoms of significant concern. Once again none of these concerning symptoms were present to merit an inpatient setting/evaluation. 

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 full hospital admission is not substantiated.