Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rhinovirus/enterovirus. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for an inpatient hospital admission. 

The denial is upheld. 

The patient is a male with a past medical history notable for recurrent ear infections and a facial port wine stain that was referred to the Emergency Department for assessment and management of non-bilious, non-bloody vomiting, non-bloody loose stool and weight loss. The patient's chronic symptoms appeared to increase over the last few days associated with lethargy, decreased oral intake, and decreased wet diapers. There was no associated fever, GI (gastrointestinal) bleeding, or dysuria. The patient's vitals on arrival were notable for HR (heart rate) of 129, Temp (temperature) of 96.6 F (Fahrenheit), RR (respiration rate) of 25, and room air oxygen saturation of 95% (percent). Admitting weight was 10.3 kilograms (1.3-kilogram loss over 1 month) and height was 78.5 centimeters (50-75th percentile for age). Physical exam showed a sleepy but arousable, ill-appearing, pale male. He had dry mucus membranes with normal capillary refill. Admitting laboratories were notable for sodium 141, potassium 4.8, bicarbonate 23, BUN (blood urea nitrogen) 13, creatinine 0.2, white blood cell 11.1 without a left shift (neutrophils 43.5%), hemoglobin 11.2, platelet 551, lactate 1, albumin 3.1, AST (aspartate aminotransferase) 22, ALT (alanine aminotransferase) 8, AP (alkaline phosphate) 91, and lipase 8. Nasal viral washings were positive for rhinovirus/enterovirus. 
 
This child appears to have chronic failure to thrive associated with an active viral upper respiratory infection, giardia gastroenteritis and mild to moderate dehydration that resolved by the time of admission to the inpatient setting. In accordance with a review of the approach to nausea and vomiting 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. He did not meet any of these criteria to merit the inpatient setting. 

Although the degree of hypovolemia is a continuum, hypovolemia is divided into three clinical categories primarily for management decisions based on the above findings: 

1) Mild dehydration (3 to 5 percent volume loss) - A history of fluid losses may be the sole finding, as clinical signs may be absent or minimal. Such patients may have a reduction in urine output, but this may not be appreciated. 2) Moderate dehydration (6 to 9 percent volume loss) - Signs and symptoms are now apparent and can include the following: tachycardia, orthostatic falls in blood pressure, especially with orthostatic changes, decreased skin turgor, dry mucous membranes, irritability, decreased peripheral perfusion with a delay in capillary refill between two and three seconds, and deep respirations with or without an increase in respiratory rate. There may be a history of reduction in urine output and decreased tearing, and, in infants, an open fontanelle will be sunken on physical examination. 3) Severe dehydration (greater than or equal to 10 percent volume loss) - Such children typically have a near-shock presentation as manifested by hypotension, decreased peripheral perfusion with a capillary refill of greater than three seconds, cool and mottled extremities, lethargy, and deep respirations with an increase in rate. 

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient. 

The insurer's denial of coverage for inpatient hospital services is upheld. Medical necessity is not substantiated.