Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dehydration; Viral Gastroenteritis

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This is an infant male patient with no significant past medical history who was brought to the Emergency Department (ED) for evaluation of fever, non-bloody, non-bilious vomiting and non-bloody diarrhea for the past 2-4 days.  The patient had nasal congestion and was taking less oral intake than usual.  There was no reported weight loss, bleeding, abdominal distension, dysuria or sick contacts.  The patient's vital signs on ED arrival were notable for Heart Rate 126 Temperature 104.3 F, Respiratory Rate 26, and room air oxygen saturation of 99%.  The patient's admitting weight was 9.3 kilograms and his height was 52.5 centimeters.  The patient's physical exam showed a fatigued patient in no apparent distress.  The patient had nasal crusting, but moist mucus membranes and good skin turgor.  The patient's capillary refill was 3-4 seconds.  The patient's lungs were clear and abdomen was soft with active bowel sounds.  The patient's laboratory results were notable for sodium 135, potassium 4.3, BUN 17, creatinine 0.3, bicarbonate 15, glucose 81, white blood cell count 6.6 without a left shift (Neutrophil 53%), hemoglobin 10.8 and platelets 331.  No urinalysis was submitted for review.  The patient received two 200cc boluses of normal saline followed by intravenous (IV) fluids at 60cc/hour.  In addition, the patient received IV Zofran and rectal Tylenol.  No imaging was performed. The patient's capillary refill improved to 2 seconds and he was noted to have 3 wet diapers while in the ED. He tolerated breast feeding for 5 minutes, but remained tired.  The patient was admitted for further hydration with a diagnosis of viral gastroenteritis and dehydration. He remained afebrile and had no recurrent vomiting.  The patient's IV fluids were decreased and he was permitted a clear diet with breast feeding thereafter, which he tolerated well.  No antibiotics or additional anti-emetics were given.  No laboratories were repeated. The patient's heart rate varied between 120's and 140's beats per minute during the admission.  
 
The patient's physical exam, vitals, and laboratories suggest that he was mildly to moderately dehydrated on ED presentation that resolved by the time of admission.  The patient's vomiting resolved with a single dose of Zofran and IV fluids. 

Based on review of literature, the reasons to admit would include signs of significant dehydration poorly responsive to IV hydration, hemodynamic instability, significant electrolyte imbalance, oral hydration intolerance, poorly controlled pain with an oral pain medication regimen, concerning exam findings for a surgical process, significant blood loss or bowel obstruction.  In this case, the patient's physical exam, laboratories and clinical course in the ED course excluded conditions that would merit inpatient acute care setting.  The patient's fatigue and ketosis prior to treatment were insufficient to merit the acute care setting especially since his dehydration had clinically resolved prior to inpatient admission and there is clear documentation of patient's tolerance to oral fluids intake.  

The patient's care could have been more appropriately delivered in an alternative setting with bolus fluids in the ED and anti-emetics followed by an oral liquid diet. Additional oral anti-emetics and oral antipyretics could have been easily and more appropriately been given in the ambulatory setting.  Based on the review of the medical record, this patient received no acute level of care. Thus, inpatient admission was not medically necessary for this patient.

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

The carrier's denial of coverage for the inpatient hospital services should be upheld.  The medical necessity is not substantiated.