Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vomiting
Treatment is an inpatient admission
The insurer denied coverage for an inpatient admission
The denial is overturned.

The patient was a female with a past medical history of sickle cell trait, constipation, peri-natal hypoglycemia (infant of a diabetic mother) and umbilical hernia that re-presented to the Emergency Department for reassessment and management of worsening intermittent non-bilious, non-bloody vomiting x 2 days up to 16 episodes the day of presentation. Evaluation then included an abdominal sonogram that was unremarkable and an abdominal X-ray that showed no obstruction but some stool burden. She was treated with a glycerin suppository and discharged home. The child returned because the vomiting was increasing in frequency and the child seemed to have abdominal discomfort. There were no associated fevers, gastrointestinal bleeding, diarrhea, weight loss or dysuria. Other family members had upper respiratory tract symptoms but no vomiting.

The patient's initial vitals were notable for a Heart Rate of 145 bpm (beats per minute), Temperature 37 degrees C (Celsius), Respirations 38 bpm, and a room air oxygen saturation of 100% (percent). The physical exam showed an awake and alert infant in no apparent distress. She had moist mucus membranes with normal capillary refill. Lungs were clear with normal effort. Cardiac exam was unremarkable. The abdomen was soft on examination. There was no associated pain, organomegaly, distension, rebound, guarding or masses. There was no rectal exam reported. Admitting laboratories were notable for sodium 139, bicarbonate 19, BUN (blood urea nitrogen) of 14, creatinine 0.42, and glucose 68. A nasal swab was negative for RSV (Respiratory syncytial virus), COVID (Coronavirus disease) and influenza A/B. No urinalysis was submitted for review. She was given Zofran 1mg (milligrams) orally x 1 but continued to vomit. The point of care glucose was 62 then 73. She received two 146cc (cubic centimeter) normal saline boluses followed by D (dextrose) 5 normal saline at 30cc/hour. No repeat imaging was performed. No additional medications were administered.

The patient was admitted for intractable vomiting and dehydration. Her admitting weight was 7.3 kilograms, and her height was 69.4 centimeters. Once admitted she continued to vomit at least twice per day. She received additional Zofran 1mg orally and a 3rd normal saline bolus of 146cc. Constipation was treated with a glycerin suppository and several doses of Miralax leading to some loose stools. She did not require pain medications. She remained afebrile the entire admission and after the interventions the vomiting abated permitting discharge.
 
The documentation of this child's appearance and vitals would indicate minimal to mild dehydration on presentation that never progressed with fluid resuscitation and maintenance fluids. After oral and intravenous glucose infusion she corrected and maintained her serum glucose. Despite no significant dehydration, her poor intake and persistent vomiting would likely have led to volume depletion had she not been admitted and treated with intravenous fluid support that did not appear possible with oral rehydration therapy alone. Although she appeared to be admitted more for her second presentation rather than for the acuity of her current state this turned out to be necessary given the persistent vomiting.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission services is substantiated.