Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.
 

This is a young child with sick cell disease (HbSS), asthma, vitamin deficiency who presented to the emergency department (ED) with a 4-day history of diarrhea, abdominal cramping (relieved after stooling), congestion, nausea, retching and decreased appetite. He was admitted for hydration. 

Per ED triage note: complaint of (c/o) abdominal pain with diarrhea (on average 4 episodes per day) and nausea. Patient is alert with dry mucosa. Abdomen is soft. pulse 125, Blood Pressure 109/69, Temperature 99.9 degrees F (Fahrenheit), Respirations 28.

Per attending physician: patient (Pt)is well appearing, no acute distress, nontoxic, dry lips, Lungs clear, abdomen soft, nontender, nondistended. Extremities warm and well perfused.

Per attending physician note, "due to low bicarb, will admit for hydration as patient is severely dehydrated and suffering ongoing losses with diarrhea and unable to keep up with losses---likely acute viral gastroenteritis. 

Heme/Oncology consulted endorsing 4 days of diarrhea with upset stomach. Recently given transfusion for sickle cell crisis. No fever, vomiting, sore throat or cough. On exam: mucous membranes are dry, otherwise normal examination-recommended labs, intravenous fluid (IVF) and re-evaluation.

Admitted with plan to wean IVF as oral (po) intake improved. Upon arrival to the floor, per RN note: patient received from ED. Pt is awake and well appearing. Pt placed on 0.5 liter (L) oxygen by nasal canula while sleeping. IV fluids given as tolerated. Patient reported minimal to no pain. Vital signs stable and afebrile.

Per RN (registered nurse) note tolerating apple juice and chicken tenders with no emesis.  Plan to discharge home. Pt was discharged with hematology clinic follow up. 

A Practice Parameter issued by the American Academy of Pediatrics pertaining to children has recommended that children with acute gastroenteritis with mild to moderate dehydration be treated with oral rehydration.(1) While oral rehydration is preferred, in children who fail oral rehydration, administration of rehydration fluids intravenously is effective and should be recommended.(2)  According to 2014 guidelines for the management of acute gastroenteritis in children, indications of hospitalization for acute gastroenteritis in this population include shock, severe dehydration, neurological abnormalities (lethargy, seizures, etc.), intractable or bilious vomiting, failure of oral rehydration, and/or suspected surgical condition.(3) 

Although this child may qualify for being moderately dehydrated, there was no evidence of failure of oral rehydration in ED (in fact there was no comment on whether oral rehydration was attempted and failed) or intractable or bilious emesis. There was no comment on whether diarrhea was present in ED or on the inpatient floor to account for the ongoing losses/inability to keep up with losses (as stated in the admission note) that would have placed patient at a high risk for further dehydration. 

In the case of this child, as per the indications above, inpatient care was not warranted. 

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 the inpatient admission is not substantiated.