Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever, vomiting and cough. 
Treatment: Inpatient hospital admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 
 
This is a child with mild asthma and speech delay who presented to the emergency department (ED) with fever, vomiting and cough times 4 days in addition to not having a bowel movement (BM) for one week. In ED, Pulse 148, Point of Care (POC) glucose 63 (on chemistry glucose within normal limits (WNL)). She was given intravenous (IV) normal saline (NS) bolus x 2 and Zofran. Decision was made to admit the patient for IV hydration. 

This child presented with cough, fever, abdominal pain, multiple episodes of emesis  with concern for dehydration in the ED. Weight prior to presentation is not available to assess percent loss of body weight as a means to determine degree of dehydration. IV fluid boluses given though almost 4 hours after initial presentation. On multiple occasions, it was noted that patient responded well to IV fluids, maintained good urine output. Despite this, decision was made to admit for IV fluid and observation. 

A Practice Parameter issued by the American Academy of Pediatrics pertaining to children aged 1 month to 5 years has recommended that children with acute gastroenteritis with mild to moderate dehydration be treated with oral rehydration.(1) While oral rehydration is preferred, in children who fail oral rehydration, administration of rehydration fluids intravenously is effective and should be recommended.(2) According to 2014 guidelines for the management of acute gastroenteritis in children, indications of hospitalization for acute gastroenteritis in this population include shock, severe dehydration, neurological abnormalities (lethargy, seizures, etc), intractable or bilious vomiting, failure of oral rehydration, and/or suspected surgical condition.(3) 

In this child's case there was likely mild dehydration on admission and after patient received IV fluid boluses x 2, patient was improved. Despite this, a decision was made to admit for IV fluid. There was no comment on whether patient had ongoing losses (i.e. episodes of emesis) in ED or during the hospital admission. There was no comment to suggest failure of oral rehydration or oral (po) refusal. Upon arrival to the floor, it was noted that patient was well appearing without physical examination findings to suggest dehydration. 
 
A publication from the Morbidity and Mortality Weekly Review (MMWR) (of the Centers for Disease Control (CDC)) states that regarding the management of acute gastroenteritis in children: 

"Inpatient care is indicated for children if 

- caregivers cannot provide adequate care at home;
- substantial difficulties exist in administrating ORT, including intractable vomiting, ORS refusal, or inadequate ORS intake;
- concern exists for other possible illnesses complicating the clinical course; 
- ORS treatment fails, including worsening diarrhea or dehydration despite adequate volumes; 
- severe dehydration (>9% of body weight) exists; 
- social or logistical concerns exist that might prevent return evaluation, if necessary, or. 
- such factors as young age, unusual irritability or drowsiness, progressive course of symptoms, or uncertainty of diagnosis exist that might indicate a need for close observation."(4) 
 
In this case the child did not fit the criteria for admission (based on above) given overall initial improvement of hydration status and labs after IV bolus x 2. There was no evidence of hemodynamic instability. 

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 is not substantiated.