Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute gastroenteritis.
Treatment: Inpatient stay.
The insurer denied the inpatient stay.
The denial is upheld.

The patient is a male child with medical history significant for obesity, ADHD (attention deficit hyperactivity disorder) treated with methylphenidate and guanfacine, pre-diabetes treated with metformin, and recently diagnosed primary hypertension on enalapril. He presented to the ED (emergency department)  for the second time with two-day history of nausea/vomiting, intermittent diffuse crampy abdominal pain, and watery non-bloody diarrhea. During the first visit, he was treated with fluids and had some lab work done, was treated and discharged home. He had no further vomiting, but the following day the abdominal pain returned and he had numerous water diarrhea stools, prompting the family to contact EMS (emergency medical services).

The patient's vital signs in the ED (emergency department) included temperature 98.7, heart rate 133, and respiratory rate 20. Examination was significant for no apparent distress, tachycardia, normal oral mucosa, abdominal tenderness in the epigastrium and bilateral lower quadrants, no guarding or rebound, and good perfusion. He had been given the diagnosis of gastroenteritis the day prior, with no changes in suspected diagnosis at this visit. Laboratory studies were significant for low normal CO2 (carbon dioxide) (21), lipase 11, amylase 26, mild hyponatremia (133), elevated WBC (white blood count) (14.22K) with elevated platelets (441K), and negative urinalysis. CRP (C-reactive protein) and ESR (erythrocyte sedimentation rate) from the previous presentation were both elevated (46 and 15, respectively).

Interventions included Zofran, Maalox and Pepcid for signs of gastritis (epigastric pain), and oral rehydration. The patient was also given Tylenol and Toradol for pain. Because of persistent tachycardia and ongoing diarrhea, with suspicion for ongoing dehydration with inadequate oral intake, he was given an IV (intravenous) fluid bolus and admitted for observation for intractable abdominal pain in the setting of likely gastroenteritis with persistent diarrhea. Of note, he voided while in the ED (emergency department) and reported being hungry and wanting to eat.

Admission orders included IV (intravenous) fluids, Zofran as needed, Tylenol as needed, serial abdominal exams, and diet as tolerated. The patient continued to have watery diarrhea overnight with one episode of vomiting in the early morning and abdominal pain that resolved after that. The IV (intravenous) fluids were subsequently discontinued later in the morning and he was tolerating his diet. He was deemed stable for discharge that evening. However, because he continued to have watery diarrhea, the family was not comfortable going home, so he remained until the following day, at which time he was successfully discharged.

No, the Inpatient admission was not medically necessary.
Acute gastroenteritis is a major problem worldwide, representing one of the leading causes of morbidity and mortality in children. There are an estimated 2.5 million deaths each year attributable to gastroenteritis in children under the age of 5 years. Most cases are caused by viruses, are self-limited, and require supportive treatment. According to the World Health Organization, oral rehydration therapy is the treatment of choice, particularly where diarrhea is the prominent feature and dehydration is mild to moderate. Intravenous rehydration is indicated when oral rehydration fails or when output is excessive. Vomiting limits the success of oral rehydration, prompting use of anti-emetic medications. Hospitalization may be necessary for those that do not respond to oral hydration and anti-emetic treatment, as well as those with severe dehydration and/or ongoing fluid losses that cannot be successfully managed with oral rehydration. In some cases of diarrhea, the output is so significant that that child is unable to drink enough to replace losses and meet fluid requirements. Anti-diarrheal agents are not indicated in the pediatric population except under very specific circumstances (e.g., dumping syndrome, short bowel syndrome).

In this patient, he presented twice to the ED (emergency department), first with vomiting, diarrhea, and abdominal pain with improvement following ED (emergency department) interventions. However, the abdominal pain and diarrhea returned, with significant fluid losses that he could not manage with oral hydration alone. While it was not unreasonable to provide parenteral hydration and monitor for resolution of diarrhea and adequacy of oral intake, the patient was overall hemodynamically stable with no evidence of impending circulatory collapse or severe underlying condition. He did not require acute inpatient admission and could have been safely managed at a lower level of care, such as observation.