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

The patient has a benign past medical history and presented to the Emergency Department (ED) for assessment and management of non-bloody, watery diarrhea x 3-4 days and one episode of non-bilious, non-bloody vomiting of Pedialyte, followed by food refusal and decreased activity. He continued to have wet diapers. There was no associated gastro-intestinal (GI) bleeding, pain, known weight loss, lethargy, sick contacts or dysuria. Of note, the patient had returned from travel abroad 7 days prior and was seen at Urgent Care the day prior to admission. The patient's vitals on arrival were notable for Heart Rate 131, Temperature 98.7 F, Respiratory Rate 24 and room air oxygen saturation of 100% (percent). Admitting weight was 12.2 kilograms. Physical exam showed a non-toxic male child in no apparent distress. He had nasal congestion. He had capillary refill < 2 seconds. There was a soft tissue mass by his right clavicle (? Lymph node). Lungs were clear with normal effort. Cardiac exam was unremarkable. Abdomen exam was soft. There was no associated pain, organomegaly, distension, rebound, guarding or masses. There was no rectal exam reported. Admitting laboratories were notable for sodium 136, potassium 4.5, bicarbonate 11, blood urea nitrogen (BUN) 17, creatinine 0.5, glucose 48, calcium 9.4, white blood cell 16.5 with left shift (72% neutrophils, 1% bands), hemoglobin 13, platelet 417, albumin 4, bilirubin 0.3, aspartate transaminase (AST) 47, alanine transaminase (ALT) 26, alkaline phosphatase (AP) 360 and venous lactate 3. 
  
This child appears to have a viral gastroenteritis (upper respiratory tract symptoms, self-limited vomiting that resolved before presentation and loose stools) and mild dehydration that resolved by the time of admission to the inpatient setting. He did not appear significantly dehydrated on presentation and improved with modest fluid resuscitation. He demonstrated the ability to tolerate oral intake and rehydration when offered, prior to the transfer. 

The reasons to admit such an individual would include signs of significant dehydration poorly responsive to intravenous hydration in the Emergency Department, significant weight loss, profound lethargy, hemodynamic instability, significant electrolyte imbalance, demonstrated oral hydration intolerance to oral challenge, 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. The child did not meet any of these criteria to merit the inpatient setting. The measures in the Emergency Department did not address his fluid deficit and could have been continued using oral rehydration as an outpatient. His low bicarbonate likely represented stool losses and his lactate was likely related to the manner in which the blood was obtained (venous sample) rather than secondary to poor tissue perfusion.
  
The documentation of this child's appearance and vitals would indicate minimal to mild dehydration on presentation that resolved with modest intravenous resuscitation (no saline bolus). His laboratory abnormalities were not critical and would be expected to correct with fluid resuscitation to clear ketones followed by oral rehydration therapy. After admission he was merely observed with both intravenous and oral fluids, and safely discharged on oral fluids with outpatient follow-up shortly after admission. Oral rehydration with or without solids could have been administered as an outpatient after demonstration of the ability to rehydrate enterally in the Emergency Department. 

Based on the above, the insurer's denial must be upheld.   The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital admission services is not substantiated.