Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastroenteritis
Treatment: Hospital admission
The insurer denied the hospital admission.
The health plan's determination is overturned.

The patient is a female with a past medical history of lupus and hypertension (HTN) who presented to the emergency room with diarrhea abdominal pain, nausea and vomiting. She had recently traveled to the Dominican Republic. She was found to have a salmonella infection and was treated with oral antibiotics, but she did not improve. She continued to have diarrhea, high fevers and lethargy. On presentation to the emergency room (ER), she was hemodynamically stable and afebrile. Her abdominal examination was benign. She did not have leukocytosis or anemia. She did not have an acute kidney injury but had mild hypokalemia. A computed tomography (CT) scan of the abdomen showed acute colitis. She was started on intravenous (IV) fluids and was admitted as an inpatient. She was evaluated by a gastroenterologist who recommended supportive care. The infectious disease consultant recommended IV Ceftriaxone. She continued to have fevers during her hospitalization and developed hearing loss. Neurology and ear, nose, and throat (ENT) were consulted for evaluation. Her symptoms gradually resolved and she was discharged to home with outpatient follow up.

Based on the available records and the criteria referenced, it was medically necessary for the patient to be treated at the inpatient level of care. Although the patient had no evidence of hemodynamic instability and had a benign abdominal examination without peritoneal signs, she did have systemic inflammatory response syndrome (SIRS) and evidence of severe nontyphoidal salmonella gastroenteritis, requiring IV antibiotics. 

Salmonellae are motile gram-negative bacilli that infect or colonize humans, causing a number of clinical infections with different clinical features like gastroenteritis, enteric fever, bacteremia and a chronic carrier state. Enteric fever is caused by Salmonella typhi (S. typhi) and Salmonella paratyphi, while other strains of Salmonella are known as nontyphoidal strains (NTS). The NTS typically causes gastroenteritis, while S. typhi causes systemic disease through the use of virulence factors. For enteric fever, the onset is gradual and the patient can present with fever and constitutional symptoms such as headache, malaise and lethargy. Other physical manifestations include abdominal pain, dactylitis, hepatosplenomegaly and a blanching erythematous macular or maculopapular rash famously known as rose spots. Early symptoms include either pea soup diarrhea or constipation. Severe presentations may also further develop into sepsis, shock and an altered mental status from potential meningitis. Bloody diarrhea can occur in a small portion of enteric fever patients. The gold standard for the diagnosis of a Salmonella infection is by the culture at the focus of the infection. The options for culture include stool, blood, urine, bile, cerebrospinal fluid and bone marrow. In most cases, treatment focus should be on the correction of dehydration and electrolyte disturbances. Supportive care is necessary for acute diarrhea and dehydration symptoms. Antipyretic therapy may also be provided if needed. Uncomplicated NTS localized to gastroenteritis without sepsis symptoms is not treated with antibiotics except in patients less than 3 months of age and patients with immunocompromised states. Once NTS gastroenteritis is identified, blood cultures should be obtained. In the setting of NTS bacteremia or disseminated disease, initial therapy should be with third generation cephalosporins like Ceftriaxone for at least 7 to 10 days. Once the bacterial susceptibilities are known, antibiotic treatment can be transitioned to Azithromycin or a Fluoroquinolone. The duration of treatment may be extended in certain focal infections such as meningitis (4 weeks) or osteomyelitis (4 to 6 weeks).