Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute gastroenteritis
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld   
The patient was a then toddler with a past medical history of ectrodactyly status-post repair with casting and persistent left superior vena cava that presented to the Emergency Department (ED) complaining of non-bloody, non-bilious vomiting x 5 hours (10 episodes), decreased urine output and loose, non-bloody stool x 2-3 weeks. There was no associated fever, upper respiratory infection symptoms, sick contacts, travel or weight loss. The patient was eating well the previous day but is a picky eater hampered by his upper extremity casts. The patient's vital signs were notable for heart rate 136, temperature 36.5 Celsius, respiratory rate 28, and room air oxygen saturation of 99%. Physical exam showed a very tired, pale uncooperative child crying with tears. Physical exam was unremarkable. The patient had a diaper rash. There was no rectal exam reported. Admitting laboratories were notable for sodium 140, potassium 4.6, bicarbonate 13, blood urea nitrogen (BUN) 25, creatinine 0.51, glucose 56, white blood count 18.3k with left shift (78% neutrophils, no bands), hemoglobin 10.9, platelets 381, erythrocyte sedimentation rate (ESR) 12 and venous lactate 2.4. No urinalysis was submitted for review. The patient's admitting weight was 10.6 kilograms, and height was 79 centimeters. The point of care glucose was 62 that increased to 204 after receiving Dextrose 5% Water (D5W) bolus which was changed to normal saine. In addition, the patient was given intravenous Zofran 1.6 milligram (mg). No imaging was performed. The decision to admit the patient to the inpatient unit for dehydration and hypoglycemia in the setting of acute gastroenteritis occurred. Once admitted the patient received intravenous fluids and an oral diet that was well tolerated. There were no episodes of diarrhea or vomiting throughout the admission. The patient remained afebrile throughout the admission. No pain medications or anti-emetics were required. No repeat laboratories were sent. 
 
This child appears to have acute gastroenteritis with self-limited vomiting x several hours and chronic diarrhea x 2-3 weeks with minimum dehydration. Although intake was overall decreased, the patient was never significantly dehydrated. In accordance with a review of the approach to acute viral gastroenteritis in resource rich countries in infants and children from UptoDate the reasons to admit such an individual would include signs of significant dehydration poorly responsive to intravenous hydration in the Emergency Department, significant weight loss, profound lethargy, hemodynamic instability, significant electrolyte imbalance, demonstrated oral hydration intolerance to oral challenge, poorly controlled pain with an oral pain medication regimen, concerning physical exam findings for a surgical process or findings consistent with significant blood loss or bowel obstruction. The patient did not manifest any of these criteria to merit the inpatient setting. Certainly, vomiting that resolved prior to the decision to admit and residual chronic loose stool did not require the acute inpatient setting. 
 
The suggestion from the appeal that this child's low bicarbonate and metabolic gap acidosis was from tissue hypoperfusion was inconsistent with the patient's vital signs and physical exam. The low bicarbonate was likely related to stool losses and the gap acidosis was related to ketosis that would clear with glucose and hydration in the Emergency Department. 

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 inpatient admission is not substantiated.