Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Vomiting, Diarrhea
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient presented to the emergency room (ER) with the mother and a friend for vomiting and diarrhea. He was admitted for observation due to safety concerns. In the ER, the mother stated initial concerns for vomiting and diarrhea times (x) 1 day then later stated concerns for the inability to appropriately care for her newborn. The mother has a history of depression (used to be on Abilify and was switched to Zoloft for breastfeeding). The mother started Zoloft 2 weeks ago and reported compliance. The mother called her friend a few days prior to presentation and asked if she could care for her baby and the friend called child protective services (CPS). The patient's grandmother, with whom they live, was reportedly unable to help with the baby due to severe arthritis. The child was evaluated and found to be in stable condition. The patient's mother was subsequently admitted to inpatient psychiatry for postpartum depression thus the baby was admitted to inpatient pediatrics for observation/social hold, pending placement by CPS.
During admission, the child was feeding and voiding appropriately. The physical exam was normal with no obvious deformities or abrasions noted. Vital signs were stable and within normal limits. Coronovirus disease 2019 (COVID-19) testing was negative. The infant showed adequate weight gain with the current weight 2900 grams (g) and birth weight 2505 g. Continued feeds every three hours (q3hrs) with burping and upright positioning 15 minutes prior to laying flat were advised. Social work (SW) consulted. CPS was contacted who noted an ongoing open case. The infant release form was signed by the mother as her immediate family could not accept care due to medical condition. Infant was released to Administration of Children's Services. The patient was discharged in stable condition to follow up with the primary medical doctor (PMD) in 1 week for a well check.
At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was medically necessary for this patient. This patient was brought to the ER by his mother, initially with complaints of vomiting and diarrhea but she later admitted to feeling unable to care for the child. The child was examined and evaluated and noted to be in stable condition with no acute medical concerns. The mother was evaluated and admitted to the psychiatric ward for treatment of postpartum depression. At the time of mother's admission, there was no other caregiver available to discharge this child safely to. The father of the child was unknown, the mother's boyfriend, who lived with them, was out of state and the child's grandmother, who also lived with them, was reportedly unable to care for the child due to her own medical condition. Given this information, the only option would be admission for further care until a safe discharge can be arranged by social services. Inpatient admission at times becomes medically necessary when social or logistical concerns exist as they may greatly impact the patient's health and safety. The American Academy of Pediatrics recommends: "1. In communities with no specialized child protection centers, children requiring evaluation and treatment for suspected abuse or neglect be hospitalized for their initial management until they are determined to be medically stable and safe alternative facilities for their placement are available pending completion of their assessment. 2. Hospitalization of children requiring evaluation and treatment for abuse or neglect should be viewed by third-party payors as medically necessary." In this situation, there was no placement available at the time the infant presented to the ER. There was no time frame documented by the admitting physician that was available to determine if the child could be held in the ER pending placement. As those details were not readily available, the only option would be admission to safely care for the child until a disposition could be made by social services.