Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain.
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is upheld.

 
This is a young child who presented to the emergency department (ED) (per primary care physician (PCP) referral) with diarrhea x 3days, vomiting fever and abdominal pain x 2days. In addition, parental report of "hard abdomen alternating with soft".  In ED he was noted to be dehydrated with dry lips, dry mucus membranes, scant tears.  He was given intravenous (IV) normal saline bolus x2 with good response though with acute onset of crying and lethargy, there was concern for intermittent intussusception. Decision was made to admit the patient for IV hydration and close observation for intermittent intussusception. 

This patient presented with diarrhea, fever, abdominal pain, multiple episodes of emesis with decreased oral (PO) intake (although maintaining baseline urine output) and physical examination in ED concerning for mild clinical dehydration (dry lips, dry mucus membranes, scant tears when crying (although with normal capillary refill less than 2 seconds), elevated Blood urea nitrogen / Creatinine, low bicarbonate on bloodwork). Discharge weight not available to assess percent (%) loss of body weight. There was also a concern for possible intussusception given parental report of intermittent hard abdomen and at some point, during ED stay, patient appearing uncomfortable and lethargic (abdominal ultrasound was NEGATIVE for intussusception). On multiple occasions, it was noted that patient responded well to IV fluids, maintained good urine output though remained intermittently febrile (with expected tachycardia). Decision was made to admit for intravenous fluids (IVF) and monitoring for intermittent intussusception.
 
A Practice Parameter issued by the American Academy of Pediatrics pertaining to children aged 1 month to 5 years has recommended that children with acute gastroenteritis with mild to moderate dehydration be treated with oral rehydration. (1) While oral rehydration is preferred, in children who fail oral rehydration, administration of rehydration fluids intravenously is effective and should be recommended.(2)  According to 2014 guidelines for the management of acute gastroenteritis in children, indications of hospitalization for acute gastroenteritis in this population include shock, severe dehydration, neurological abnormalities (lethargy, seizures, etc.), intractable or bilious vomiting, failure of oral rehydration, and/or suspected surgical condition.(3) 

In this child's case there was soft evidence of mild dehydration, with recurrent emesis though patient appeared to have responded well to fluids - able to tolerate water, lactide milk prior to arriving on the floor. There was no comment to suggest failure of oral rehydration or oral refusal. Upon arrival to the floor, it was noted that patient was well appearing. 
 
In the case of this child, he did not fit criteria for admission given overall initial improvement of hydration status and labs after IV bolus x2.  There was no evidence of hemodynamic instability. The intermittent tachycardia was only present in the setting of fever or crying which is typical. In terms of intussusception, there was no further comment during the inpatient admission that frequent abdominal examination were performed, nor any notable changes in physical examination from ED to floor.

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.