Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endogenous retrovirus
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld. 
 
The patient has a past medical history notable for prematurity (34-week gestation) that presented to the Emergency Department complaining of frequent non-bloody, non-bilious vomiting for 2 days, low grade fever 100.7, and decreased oral intake. The patient had rhinorrhea but no associated cough, wheezing, shortness of breath, weight loss, decreased urine output, or dysuria. There was a sibling with similar symptoms at home. Of note, the patient was prescribed Zofran by their local provider but never received it. The father noted difficulty waking the patient and the patient appeared pale and weak. The patient's vitals were notable for blood pressure (BP) 88/57, pulse 97, Temp 99.1 degrees Fahrenheit, respirations 24, and room air oxygen saturation of 97%. Physical exam showed an awake, ill-appearing patient in no apparent distress. There was crusted nasal discharge. The patient had moist mucus membranes, cap refill of 3 seconds, and normal skin turgor. Lungs were clear with normal effort. Cardiac exam was unremarkable. Abdomen exam was soft and flat. There was no associated pain, organomegaly, distension, rebound, guarding, or masses. There was no rectal exam reported. 

The insurer is denying the acute inpatient admission as not meeting medical necessity criteria for acute inpatient admission by lack of serious findings in his vitals, labs, physical exam and history to meet Millman Care Guideline standards for Gastroenteritis, Diarrhea with Dehydration or Dysentery, Pediatric ORG: P-190 for the acute inpatient setting. A representative of the hospital is appealing citing the child's presenting symptoms and treatment - specifically the drifting serum glucose and oral intolerance leading to dehydration citing Millman Care Guidelines for Vomiting, Pediatric ORG: P-371 (ISC). The issues at hand are whether the acute inpatient admission was medically necessary and in the best interest of the patient.

The most useful clinical signs that predicted 5 percent hypovolemia in children were delayed capillary refill time, reduced skin turgor, and deep respirations with or without an increase in absolute respiratory rate. A combination of signs and symptoms was better than an individual finding at predicting hypovolemia.

The documentation of this child's appearance and vitals would indicate mild dehydration on presentation that resolved with modest fluid resuscitation and maintenance fluids. The patient appeared to be admitted for observation and supplemental intravenous fluids despite tolerating oral intake. The patient actually never received any acute care after the decision to admit the patient to the inpatient setting to merit reimbursement at this level. In regard to the acute inpatient admission, the determination by the carrier that the admission was not medically necessary was correctly applied, objective, clinically valid, compatible with established principles of health care, and flexible enough to permit justified variation. This decision was rendered based on review of the hospital record and the attached reviews from UpToDate summarizing the approach to acute viral gastroenteritis in children and dehydration in children is cited above.

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 full hospital admission is not substantiated.