Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Oral Aversion. 
Treatment: Hospital admission. 

The insurer denied coverage for hospital admission. 
The denial is overturned. 

The patient is a male with oral aversion who presented to the emergency department with fever, mouth rash for 8 days and decreased oral intake and decreased urine output one day prior to arrival. While in the emergency department, he failed an oral trial. The patient was admitted for further care. Intravenous fluids were continued and the patient's intake/output was monitored.  The insurer has denied coverage for the inpatient on the grounds that this hospitalization was not medically necessary. "The documentation provided did not meet InterQual 2020 Pediatric Acute Dehydration or Gastroenteritis criteria for admission." 

Strict intake and output (I/O) maintained throughout the hospitalization along with pain score that ranged from 8/10 to 2/10. 

This young child presented with subjective fever, mouth rash, poor oral intake and poor urine output with concern for dehydration (based on lack of urine output for most of the day on presentation to emergency department and during emergency department reassessment period). Although the patient was hemodynamically stable likely representing mild dehydration (unable to assess a change in body weight, the patient was documented to have moist mucus membrane though unclear whether the patient was crying with presence of tears on examination as this was not documented), he failed an oral fluid challenge administered in the emergency department on few occasions prompting admission for intravenous fluid administration. 
 
Although this child did not have an acute gastroenteritis, his admission was secondary to acute dehydration in the setting of failure to take oral intake. Therefore, below references will be used to support reasoning for hospitalization. 
 
In this child's case there was failure of oral hydration to maintain this patient. 
 
A publication from the Morbidity and Mortality Weekly Report (MMWR) (of the CDC) states that regarding the management of acute gastroenteritis in children: 

"Inpatient care is indicated for children if: 

1) caregivers cannot provide adequate care at home; 2) substantial difficulties exist in administrating oral rehydration therapy (ORT), including intractable vomiting, oral rehydration solution (ORS) refusal, or inadequate ORS intake; 3) concern exists for other possible illnesses complicating the clinical course; 4) ORS treatment fails, including worsening diarrhea or dehydration despite adequate volumes; 5) severe dehydration (>9% of body weight) exists; 6) social or logistical concerns exist that might prevent return evaluation, if necessary, or 7) such factors as young age, unusual irritability or drowsiness, progressive course of symptoms, or uncertainty of diagnosis exist that might indicate a need for close observation."(4) 

In the case of this child, as per the indications above (failed oral rehydration in the setting of dehydration), inpatient care was warranted. On multiple reassessment, it was noted that patient did not have wet diapers except the one reported by the mother (at home earlier in the day). Discharging this patient home could have led to more severe dehydration and clinical compromise. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for the hospital admission at an acute inpatient level of care is reversed. Medical necessity is substantiated.