Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Norovirus gastroenteritis

Treatment: Inpatient admission

The insurer denied coverage for: Inpatient admission

The denial is: Upheld 
 

Patient is an infant with a benign past medical history that presented to the Emergency Department (ED) complaining of non-bloody, non-bilious vomiting 3-4 days ago, tactile fever x 2 days (resolved), non-bloody diarrhea x 5 days, decreased oral intake, and mild cough. There was no associated wheezing, shortness of breath, weight loss, decreased urine output (having 4-5 wet diapers per day) or dysuria. The patient was eating poorly but was tolerating fluids well at home. The patient's cousin had a recent viral upper respiratory tract infection. The patient's vital signs were notable for: Heart rate 132, temperature 37.3 degrees Celsius, respirations 34, and room air oxygen saturation of 98%. Physical exam showed an alert, well-appearing child in no apparent distress. The patient had moist mucus membranes and normal capillary refill. Lungs were clear with normal effort. Cardiac exam was unremarkable. Abdomen exam was soft and flat. There was no associated pain, organomegaly, distension, rebound, guarding or masses. There was no rectal exam reported. Admitting laboratories were notable for: Sodium 138, potassium 4.8, bicarbonate 18, blood urea nitrogen (BUN) 3, creatinine 0.36, and glucose 57. Respiratory viral panel was negative for influenza A/B, respiratory syncytial virus (RSV) and Covid-19. No urinalysis was submitted for review. The patients admitting weight was 9.1 kilograms, and height was 71 centimeters. Because of the hypoglycemia the patient received 182 cubic centimeter (cc) boluses of normal saline followed by Dextrose 5 % (D5) normal saline @ 55cc/hour. In addition, the patient was given D10 intravenously. No imaging was performed. The decision to admit the patient to the inpatient unit for dehydration and hypoglycemia in the setting of acute gastroenteritis. Once admitted the patient received intravenous fluids reduced to 37cc/hour and then 5 cc/hour with oral diet that was well tolerated. There were 2 episodes of diarrhea overnight and no vomiting throughout the admission. The stool was positive for norovirus. The patient remained afebrile. No pain medications or anti-emetics were required. Repeat glucose was 98. The patient was discharged home with a heart rate of 126.
 
This child appears to have a norovirus gastroenteritis with self-limited fever and vomiting x 1-2 days followed by diarrhea x 5 days with minimum dehydration. 

The patient appeared to be admitted for observation and supplemental intravenous fluids despite passing an oral challenge and having no symptoms related to hypoglycemia. The suggestion from the appeal that any child under 1 year of age with this level of dehydration requires admission is completely unjustified. This patient actually never received any acute care after admission to the inpatient setting. The heart rate at discharge was nearly the same as at presentation even after intravenous fluids. In regard to the acute inpatient admission, the determination by the carrier that the admission was not medically necessary was correctly applied, objective, clinically valid, compatible with established principles of health care and flexible enough to permit justified variation. This decision was rendered based on review of the hospital record. 

The health plan acted reasonably, with sound medical judgment and/or in the best interest of the patient.

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.