Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vomiting, diarrhea and abdominal pain.
Treatment: Inpatient admission.
The health plan denied the inpatient admission. The denial is overturned.

The patient is a girl, who presented with abdominal pain, vomiting, and diarrhea. She was well until 2 days prior to presentation when she developed abdominal pain. She then awoke with emesis, and continued to vomit the next day. She also had 2 episodes of diarrhea. She then had another 4 episodes of emesis, so she was brought to the emergency department for evaluation.

In the emergency department, she was found to have hypoactive bowel sounds and tenderness in all 4 quadrants of her abdomen, with increased tenderness in the right upper quadrant. Laboratory values were obtained, and her urine had a specific gravity of 1.024. She received a bolus of normal saline, as well as Zofran and acetaminophen. She continued to be unable to tolerate any oral intake, including medications, and she continued to complain of pain. An ultrasound was obtained and was normal, and an abdominal computed tomography (CT) scan revealed moderately severe enteritis.
The patient was admitted for ongoing management of dehydration and abdominal pain. She was given intravenous fluids and was not allowed to eat or drink, and was prescribed Zofran as needed. The surgical and gastroenterology teams were consulted, and a stool culture was recommended. She was subsequently able to tolerate some clear liquids and her intravenous fluids were decreased. She continued to have some diarrhea. Later, she was able to advance to a regular diet, which she tolerated well. She was felt to be stable for discharge with follow-up as an outpatient.

The inpatient admission is under review for medical necessity. I overturn, in whole, the health plan's determination of medical necessity. The requested health service/treatment of an inpatient admission was medically necessary for this patient.

This is a young girl who presented with multiple episodes of vomiting, abdominal pain, and diarrhea. She was unable to tolerate oral intake in the emergency department setting despite appropriate treatment with intravenous fluids and antiemetics, and she continued to have tenderness on her abdominal exam. She, therefore, required hospital admission for treatment with intravenous fluids, specialist consultation, and monitoring with additional evaluation and treatment as needed.

The decision making at the time of admission for this patient was consistent with her young age, the presence of vomiting and diarrhea and an inability to tolerate oral intake, and the need for intravenous fluids to prevent dehydration, along with close monitoring for potential deterioration of her clinical status.

According to the Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care Guidelines, 26th edition, Gastroenteritis, Diarrhea with Dehydration, or Dysentery, Pediatric; hospitalization is indicated for patients with vomiting that is severe or persistent or with an inability to maintain oral hydration that persists after observation care.

This patient had multiple episodes of emesis and was unable to tolerate oral intake in the emergency department despite receiving appropriate care with intravenous fluids and medications. She, therefore, required hospital admission for ongoing fluid hydration, as well as repeated examination, specialist consultation, and monitoring.