Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female child. She presented to the ED (emergency department) with twenty episodes of vomiting, eventually bilious, no fevers, no apparent abdominal pain, only two episodes of diarrhea, and no known ill contacts (although sister began vomiting later that morning while in the ED [emergency department], discharged from the ED [emergency department]). She also had some cough.

The patient's vital signs included temperature 36.4, heart rate 140, respiratory rate 28. Examination was significant for active and alert appearance, normal pulses, and soft abdomen. Laboratory evaluation was significant for WBC (white blood cell) count 8.7K (thousand), hemoglobin 15.8 (hemoconcentrated), glucose 102, normal CO2 (carbon dioxide) 22, alkaline phosphatase 363, AST (aspartate aminotransferase) 52, ALT (alanine aminotransferase) 28, RSV (respiratory syncytial virus)/influenza/Covid (coronavirus disease) negative. Abdominal ultrasound was significant only for fluid-filled bowel loops throughout the abdomen, no evidence of intussusception. Chest x-ray was unremarkable. KUB (kidney, ureter, bladder x-ray) was negative.

The patient continued vomiting in the ED (emergency department) despite treatment with IV (intravenous) fluids and Zofran so was admitted for ongoing management of viral gastritis. Admission orders included maintenance IV (intravenous) fluids, clear liquid diet advancing to regular diet for age as tolerated, Zofran as needed, Tylenol as needed, and routine vital signs. She did well overnight and by the next day, she was tolerating her diet without vomiting. Repeat metabolic panel was unremarkable with slight drop in CO2 (carbon dioxide) to 20. She was deemed stable for discharge to follow-up with her primary care practitioner.

No, the Inpatient admission was not medically necessary. The patient did not require acute inpatient admission.
Acute gastroenteritis is a major problem worldwide, representing one of the leading causes of morbidity and mortality in children. There are an estimated 2.5 million deaths each year attributable to gastroenteritis in children under the age of 5 years. Most cases are caused by viruses, are self-limited, and require supportive treatment. According to the World Health Organization, oral rehydration therapy is the treatment of choice, particularly where diarrhea is the prominent feature and dehydration is mild to moderate. Intravenous rehydration is indicated when oral rehydration fails or when output is excessive. Vomiting limits the success of oral rehydration, prompting use of anti-emetic medications. Hospitalization may be necessary for those that do not respond to oral hydration and anti-emetic treatment, as well as those with severe dehydration.

This young female child presented to the ED (emergency department) with refractory vomiting, reportedly with twenty episodes at home and additional vomiting in the ED (emergency department) despite antiemetic therapy. She was unable to tolerate fluids, so required additional management in the hospital setting. However, she was overall hemodynamically stable with no evidence of impending hypovolemic shock or cardiovascular collapse; she was alert and active, and had no abdominal pathology (eg intussusception, obstruction). She did not require acute inpatient admission, and she could have been safely managed at a lower level of care, such as observation.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.