Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Viral Gastroenteritis.
Treatment: inpatient hospital admission.
The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

This newborn with a past medical history notable for neonatal jaundice presented to the Emergency Department for assessment and management of 2 days of non-bloody, non-bilious vomiting and watery stool every 3 hours. His mother notes irritability and poor appetite but reports that the child was urinating normally. There were no associated fever, rashes, abdominal pain, abdominal distention, bleeding or weight loss. An abdominal sonogram showed a dilated stomach and a 2.5 centimeter (cm) target-like lesion in the right abdomen suspicious for small bowel-small bowel intussusception. An abdominal x-ray showed non-dilated bowel with air throughout the colon, negative for obstruction. The child was given an oral challenge of breast milk that he tolerated well. A second abdominal sonogram was performed showed resolution of the aforementioned target lesion. Given the initial sonogram findings and the outpatient history of vomiting he was admitted to the pediatric intensive care unit in consultation with pediatric surgery for intravenous hydration, nothing further by mouth and observation. A third sonogram ruled out both intussusception and pyloric stenosis. He remained hemodynamically stable and vomiting and diarrhea never recurred.
 
This child appears to have had viral gastroenteritis with loose stools, self-limited vomiting and no dehydration that responded to modest intravenous fluid repletion while in the Emergency Department. The decision to admit him came after a sonogram looking for pyloric stenosis showed a possible incidental intussusception. He never demonstrated signs of bowel obstruction by physical exam, history or imaging and in fact demonstrated a successful oral challenge when permitted in the Emergency Department. In accordance with a review of the approach to acute viral gastroenteritis in children in resource-rich countries from UptoDate  the reasons to admit such an individual would include signs of significant dehydration poorly responsive to intravenous hydration in the Emergency Department, hemodynamic instability, significant electrolyte imbalance, demonstrated oral hydration intolerance to oral challenge (after treatment with anti-emetics and fluids), 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. His vomiting and loose stool at home prior to presentation that never recurred without treatment clearly does not equate to intractable vomiting as stated in the appeal.
 
The documentation of this child's history, appearance, vitals, labs and imaging would indicate that the sonogram finding of possible intussusception was an incidental finding not associated with bowel obstruction. In fact, this questionable finding actually resolved by the second sonogram prior to admission to the inpatient service.  There was no persistent vomiting and no suspected bowel obstruction as stated in the appeal. After uneventful observation, a successful oral challenge and resolution of radiologic concerns for intussusception this patient could have been safely discharged with close outpatient follow-up. This patient actually received no acute care after admission to merit that level except for continued intravenous fluids despite tolerating feeds without issue once permitted. 

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.