Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Vomiting, fever, and diarrhea.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a male child with medical history significant for non-verbal autism.  He was taken to the ED (emergency department) with two days of vomiting, fever, and diarrhea.  He was drinking but not eating, and he had not voided since the night before.  He was seen by his pediatrician the day prior and was prescribed amoxicillin for a "stomach virus."

The patient's vital signs included temperature 98.7, heart rate 132, respiratory rate 24, and blood pressure 93/55.  Examination was significant for pallor, brisk capillary refill, moist mucous membranes, dry lips, clear lungs, soft non-tender abdomen, and non-focal neurologic exam.  Blood sugar was 105.  Urinalysis was remarkable for specific gravity 1.023. 

The patient was placed in observation status in the ED (emergency department) and treated with an IV (intravenous) fluid bolus.  Laboratory evaluation revealed normal WBC (white blood cell) count, mild hyponatremia with sodium 134, mild hypokalemia with potassium 3.4, elevated CRP (C-reactive protein) 11.5, elevate sedimentation rate 18, negative rapid RNA (ribonucleic acid) COVID (coronavirus) testing, and CO2 (carbon dioxide) low end of normal at 21.  He was re-evaluated multiple times during his stay in the ED (emergency department). 

The patient slept intermittently, refusing to eat or drink beyond a sip.  He was given a second IV (intravenous) fluid bolus.  He subsequently voided.  He was admitted to the pediatric floor for inadequate oral intake.  Admission orders included serial abdominal examinations, regular diet as tolerated, IV (intravenous) fluids with correction for moderate dehydration (determined to be 6% loss), and repeat labs.  Pediatric Gastroenterology was consulted with no further recommendations due to clinical improvement. 

The next day, the patient had no vomiting but had several loose green stools.  He was drinking juice well but not eating any food.  He was comfortable and smiling.  Repeat labs demonstrated resolution of hyponatremia, potassium 3.3, CRP (C-reactive protein) 9.32, and improved CO2 (carbon dioxide) 23.  He remained on IV (intravenous) fluids and was encouraged to eat.  Labs were ordered.  He had no loose stools since late evening the day after admission and no vomiting.  He was starting to take some solids.  Laboratory evaluation continued to show improvement.  He continued to do well, so he was discharged later that day to follow-up with his pediatrician in one or two days.

No, the Inpatient admission was not medically necessary.

Acute gastroenteritis is a major problem worldwide, representing one of the leading causes of morbidity and mortality in children.  There are an estimated 2.5 million deaths each year attributable to gastroenteritis in children under the age of five years.  Most cases are caused by viruses, are self-limited, and require supportive treatment.  According to the World Health Organization, oral rehydration therapy is the treatment of choice, particularly where diarrhea is the prominent feature and dehydration is mild to moderate.  Intravenous rehydration is indicated when oral rehydration fails or when output is excessive.  Vomiting limits the success of oral rehydration, prompting use of anti-emetic medications.  Hospitalization may be necessary for those that do not respond to oral hydration and anti-emetic treatment, as well as those with severe dehydration.

In this case, this child with autism presented with vomiting, diarrhea, and decreased urine output.  He was non-verbal and unable to communicate presence or absence of abdominal pain.  His examination did not indicate significant dehydration or abdominal pathology and was overall reassuring but merited re-evaluation.  He was given IV (intravenous) hydration in the ED (emergency department) and was able to void, but he refused to take anything but sips of fluid, inadequate in volume.  It was medically appropriate to continue IV (intravenous) hydration pending his ability to take adequate fluids by mouth.  However, while it was reasonable to continue monitoring him in the hospital, he was overall hemodynamically stable with no evidence of impending shock, severe dehydration, or sepsis.  He did not require acute inpatient admission and could have been safely managed at a lower level of care, such as hospital observation.