Appeal type: Medical necessity
Decision: Upheld

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

This patient was an infant male with a benign past medical history that presented to the Emergency Department (ED) for reassessment and management of persistent non-bloody watery diarrhea, fatigue and decreased oral intake for 3 days. He was tolerating 2 ounces every 3 hours and continued to have wet diapers. There were no associated fevers, vomiting, gastrointestinal (GI) bleeding, pain, known weight loss, rashes, cough, or sick contacts. Of note, the patient was seen with fever, vomiting and diarrhea and told to return if symptoms persisted. The patient's vitals on arrival were notable for heart rate (HR) 128, temperature 97 Fahrenheit, respiratory rate (RR) 30 and room air oxygen saturation of 98% (percent). Imaging included a chest x-ray showing patchy left basilar/retrocardiac infiltrate and an abdominal x-ray that was unremarkable. He was admitted for acute gastroenteritis and dehydration. His vomiting had resolved before presentation, but loose stools persisted. His weight on the floor after hydration was 10.2 kg (kilogram) and his height was 30 inches. He was afebrile throughout the admission. He tolerated at least 4 ounces per feed and his intravenous (IV) fluids were weaned off. He continued to tolerate oral intake and loose stools were better by the morning of 6/17. His HR ranged between 120 - 143 during the short admission. Urine output continued to be good. Repeat laboratories on 6/17 were notable for sodium 138, potassium 4.4, bicarbonate 24, BUN (blood urea nitrogen) <(less then) 3, creatinine 0.2 and glucose 88. No medications were administered after admission. Stool polymerase chain reaction (PCR) was positive for three different Escherichia coli (E. coli) species, Shigelloides and Shigella. He was discharged home for outpatient follow-up with a HR 138.
 
This child appears to have a viral gastroenteritis (self-limited vomiting followed by several days of loose stools) and minimal to mild dehydration that resolved by the time of admission to the inpatient setting. He did not appear dehydrated on presentation (moist mucus membranes and dilute urine) and his lethargy and oral intake significantly improved with modest fluid resuscitation prior to admission to the inpatient setting. He did demonstrate the ability to tolerate oral intake even prior to presentation. The documentation of this child's appearance, his vitals and the weight percentage difference after hydration would indicate minimal to mild dehydration on presentation that resolved with IV resuscitation. His presenting heart rate was higher than most of his inpatient values including at the time of his discharge. His laboratory abnormalities were not critical and would be expected to correct with fluid resuscitation to clear ketones followed by oral rehydration therapy. He appeared to be admitted more for his return visit and observation than the severity of his condition at presentation. After admission he was observed with both IV and oral fluids, and safely discharged on oral fluids with outpatient follow-up shortly after admission. He actually received no acute care after admission to merit reimbursement at that level. Oral rehydration with or without solids could have been administered as an outpatient after demonstration of the ability to rehydrate enterally in the ED. 

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 admission is upheld. Medical Necessity is not substantiated.