Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Viral Gastroenteritis, Intractable Vomiting

Treatment: Inpatient admission.

The insurer denied the inpatient admission. 

The denial was upheld.

This is a  patient a male with a medical history who presented to the Emergency Department (ED) for assessment and management of low grade fever of 100.7 F, non-bloody, non-bilious vomiting x 1 day (4 episodes) and diarrhea the day prior (up to 6 episodes). The patient's mother noted that the patient had decreased oral intake of solids, a new rash formation and no wet diapers for the past several hours.  There was no associated upper respiratory infection (URI) symptom, sick contacts, travel, or weight loss.  The patient's initial vitals in the ED were notable for heart rate of 180, temperature of 99.68 F, respiratory rate of 30, and oxygen saturation of 96% in room air. The patient was awake and alert.  The patient had moist mucus membranes with normal capillary refill. The patient was drooling but crying without tears. The patient's lungs were clear to auscultation, and his cardiac exam was unremarkable. The patient's abdomen exam was also unremarkable with soft to palpation with normal bowels sounds. The patient had a fine macular rash on his trunk and extremities. The patient's admitting laboratory results were notable for sodium 137, potassium 4.3, bicarbonate 16, BUN 13, creatinine 0.35, glucose 55, white blood cell 7.7 without a left shift (neutrophils 64%, no bands), hemoglobin 13.3, platelet 279, amylase 38, lipase 20 and a normal liver profile. The patient's urinalysis was notable for specific gravity 1.030, pH 5.5 and dip + for large ketones. The patient's nasal viral washings were negative for Influenza and RSV.  The patient's rapid strep test was negative. The patient received intravenous (IV) fluid boluses and IV Zofran. The patient was tolerating some liquids by mouth.  The patient was admitted to the hospital with viral gastroenteritis and intractable vomiting. The patient's vomiting had stopped and he was advanced to a regular diet. After a period of medical stability the patient was discharged home.
This patient appeared to have viral gastroenteritis with self-limited diarrhea (resolved by hospital presentation) and vomiting with mild dehydration that responded well to intravenous fluid repletion while in the Emergency Department.  The decision to admit the patient occurred while the patient was receiving his second fluid bolus and despite the patient's ability to take fluids by mouth.  In accordance with a review of the approach to nausea and vomiting in children from UpToDate, the reasons to admit such an individual would include signs of significant dehydration poorly responsive to intravenous hydration in the Emergency Department, hemodynamic instability, significant electrolyte imbalance, demonstrated oral hydration intolerance to oral challenge (after treatment with anti-emetics and fluids), poorly controlled pain with an oral pain medication regimen, concerning physical exam findings for a surgical process or findings consistent with significant blood loss or bowel obstruction. However, in this case, the patient did not meet any of these clinical criteria to merit the inpatient setting. 
Dehydration in children from UpToDate, the patient's clinical appearance and vitals indicated mild dehydration that resolved by the time of the decision to admit the patient to the hospital.  After bolus fluid resuscitation and anti-emetics given in the Emergency Department, the patient was urinating and tolerating oral intake. This patient could have been safely discharged home with instructions to follow-up as outpatient after a brief period of observation and hydration to clear his ketosis. 

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

The carrier's denial of coverage for the inpatient hospital admission should be upheld.  The medical necessity is not substantiated.