Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of a fever and cough for one week. Her mother states she had predominantly a mucusy cough and was seen by her primary medical doctor (PMD) 6 days prior for vomiting and decreased appetite. The PMD prescribed Zofran which improved the vomiting. The patient then developed diarrhea with decreased energy. Her mother was unsure of the number of times she has urinated due to the frequency of diarrhea. The exam on admission revealed no signs of dehydration. The patient was described as well hydrated and with moist mucus membranes. Labs done were unremarkable.  A chest x-ray (CXR) was read as mild patchy opacities within the left lung base suggestive of aspiration or pneumonia in the appropriate clinical setting.
She was admitted for mild isonatremic dehydration. On gastrointestinal (GI) polymerase chain reaction (PCR) swab she was noted to have EPEC, Sapovirus and Campylobacter. She was treated with Zofran and intravenous fluids (IVF). Tylenol was ordered every four hours as needed (q4hrs PRN). The patient improved and did not require azithromycin treatment. A clean catch UA grew 5000 colony forming units (CFU) Klebsiella and 50,000 CFU E. Coli. As the specimen was clean catch, a urinary tract infection (UTI) was not diagnosed. At admission Flu/ respiratory syncytial virus (RSV) swab was negative. The CXR showed mild patchy opacities in the left lower lobe (LLL) but due to clinical appearance and exam, no empirical treatment for pneumonia was started. The patient's IVF were weaned and by mouth (PO) intake was adequate enough to be cleared for discharge to follow up with her pediatrician in 1-2 days.
The health plan's determination is upheld. The clinical findings described in the chart along with her laboratory findings do not support a diagnosis of dehydration. There was no mention of a failed PO trial in the pediatric emergency room. She also had finding of possible infiltrate on CXR but the admitting physicians did not feel her clinical picture aligned with a diagnosis of pneumonia so she was not treated with antibiotics. Her lung exam was described as normal, she was not hypoxic nor did she have tachypnea or increased work of breathing. Oral rehydration therapy is the recommended first line for mild to moderate dehydration. She did not meet currently accepted criteria for admission to the hospital for dehydration which was her admitting diagnosis.
Current criteria for admission include:
"1) caregivers cannot provide adequate care at home;
2) Substantial difficulties exist in administrating oral rehydration therapy (ORT), including intractable vomiting, oral rehydration solution (ORS) refusal, or inadequate ORS intake;
3) Concern exists for other possible illnesses complicating the clinical course; ORS treatment fails, including worsening diarrhea or dehydration despite adequate volumes;
4) Severe dehydration (greater than [>] 9% of body weight) exists; Social or logistical concerns exist that might prevent return evaluation, if necessary
5) Factors as young age, unusual irritability or drowsiness, progressive course of symptoms, or uncertainty of diagnosis exist that might indicate a need for close observation."
The patient was treated with IVF that were quickly weaned. She was admitted for less than [<] 48 hours and had an uneventful hospital course. Inpatient level of care was not medically necessary.