Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient hospital stay. 

The health plan denied the inpatient hospital stay as not medically necessary. The reviewer has upheld in whole the health plan's determination of medical necessity. 

The patient has a medical history significant for macrocephaly, and speech and motor delays, that presented to the emergency department (ED) with a two-day history of vomiting and diarrhea. She was not as active and not drinking well with decreased urine output. Because of concern for possible pyloric stenosis, she was transferred from an outlying ED for further evaluation and possible surgical consultation. Abdominal x-ray was significant for dilated stomach and mildly distended loops of bowel with no evidence of obstruction prompting placement of a nasogastric tube for decompression. Pyloric ultrasound was limited by crying but revealed questionable wall thickness. She was treated with Zofran, normal saline bolus, and maintenance intravenous (IV) fluids. Vital signs included temperature 37.2, heart rate 139, respiratory rate 30, and blood pressure 102/59. Examination was significant for fussiness but no acute distress, moist mucous membranes, regular heart rate and rhythm, mild abdominal distension, and non-focal neurologic exam. Differential diagnosis given her age and presentation placed pyloric stenosis as an unlikely diagnosis, most likely viral gastroenteritis. She was admitted for IV fluids and overnight observation. Admission orders included IV fluids to wean as tolerated, Zofran as needed, regular diet, and Covid testing. She tolerated an oral challenge. Surgical consultation was deferred. She did well with no vomiting, drinking well and taking bites of solid foods. She was deemed stable for discharge home. 

The patient did not require acute inpatient management and could have been safely managed at lower level of care. 

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 5 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. 
This young child presented to the ED with acute vomiting and diarrhea. She was evaluated and treated with anti-emetics and IV fluids. Abdominal imaging was concerning for a thickened pylorus raising a question of pyloric stenosis even though she was outside of the typical age range. She was transferred for surgical evaluation. Upon arrival, she was already improved, able to tolerate an oral challenge in the ED. She was monitored in the hospital over the course of the day and subsequently discharged home. While it was not unreasonable to monitor her intake to determine if she was able to tolerate sufficient fluids to sustain herself, she was overall hemodynamically stable with no evidence of impending circulatory collapse or sepsis. She did not require acute inpatient admission and could have been safely managed at lower level of care.