Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epigastric Pain. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

The patient presented with severe epigastric pain on the morning of presentation. The pain did not radiate and he had 6 episodes of non-bloody non bilious (NBNB) emesis including 3 episodes in the emergency room (ER). The symptoms were preceded by 2 days of rhinorrhea and nasal congestion. Since the morning of presentation, he had decreased oral intake and activity. During physical exam, the child had no pain or distress. The patient's mother denied fever, ear pain, rash, sore throat, dysuria, cough, sick contacts or recent travel. 

Lab results in the emergency room (ER) revealed a white blood cell count (WBC) of 19.6, venous blood gas (VBG) potential hydrogen (pH) 7.31. He was treated in the emergency room (ER) with Zofran, a normal saline (NS) bolus and Ceftriaxone. Vital signs were a blood pressure (BP) of 102/60, heart rate (HR) 110, temperature (T) 97.3 degrees Fahrenheit, respiratory rate (RR) 22, and oxygen saturation (O2 sat) 100%.
His examination was notable for congestion and rhinorrhea, moist mucous membranes, and active on exam. The assessment at the time of admission states the patient was admitted for severe epigastric pain with 6 episodes of NBNB vomiting. The symptoms were preceded by 2 days of rhinorrhea and nasal congestion. A chest x-ray (CXR) was negative. The last episode of emesis was in the ER. He had 3 episodes of emesis in the ER after Zofran. The patient was well hydrated. The differential diagnosis was viral syndrome, viral gastritis, rule out (r/o) pancreatitis. The plan was for vital signs per protocol, intravenous fluids (IVF), repeat basic metabolic panel (BMP) in the AM, regular diet, Tylenol/Motrin as needed (PRN). On day of admission number (#) 2 physical exam (PE) revealed that the abdomen was soft, non-tender and had no rigidity. There was marked improvement of symptoms and resolution of pain. The patient was cleared for discharge home and was instructed to follow up with the primary medical doctor (PMD) in 2-3 days. 

At issue is the medical necessity of an inpatient stay. 

The requested health service/treatment of inpatient stay was not medically necessary for this patient. 

This patient presented with emesis that started a few hours prior to presentation to the ER and was preceded by 2 days of rhinorrhea and nasal congestion. The patient went on to have 2-3 more episodes of emesis in the ER and then resolution of his symptoms. He had a quick resolution of his symptoms with no further vomiting after leaving the ER. His laboratory values as well as the physical exam were not consistent with a degree of dehydration that would necessitate inpatient level of care. 

The Milliman Care Guidelines (MCG) for Gastroenteritis, Pediatric for inpatient level of care include, suspected severe infection, severe abdominal tenderness, hemodynamic instability, vomiting that is severe or persistent (numerous episodes of vomiting that have occurred in the past 24 hours, pattern or content of vomitus suggests severe underlying cause or complication, appropriate antiemetic treatment does not sufficiently reduce vomiting within 12-24 hours of treatment, treatment regimen necessary to adequately control vomiting requires inpatient level of care), dehydration that is severe or persistent (acute weight loss from baseline 9% in pediatric patients, hemodynamic instability, acute renal failure, serum sodium greater than (>) 150 milliequivalents per liter, oral rehydration therapy not tolerated or insufficient to adequately correct dehydration and appropriate intravenous (IV) treatment does not readily correct dehydration after 12-24 hours of treatment), neurologic abnormalities such as lethargy or seizures, hemolytic uremic syndrome (HUS) diagnosed, inability to maintain oral hydration that persists after emergency department and observation care treatment, parenteral nutrition regimen that must be implemented on an inpatient basis. The patient did not meet any of these criteria. He showed improvement by the day after admission and was cleared for discharge home. 

The patient had a quick resolution of his symptoms with no further vomiting after leaving the ER. His admission exam was normal. He did not have any physical signs of dehydration nor was he described to be in any distress. He was hemodynamically stable. He was admitted and discharged in a little over 24 hours. While admitted he did not require any highly skilled or technical care. He did not meet criteria for inpatient level of care.