Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Other/Viral Illness; Vomiting without Nausea
Treatment: Inpatient Hospital Admission
The health plan denied the requested inpatient hospital admission as not medically necessary. 
The health plan's determination is overturned.

The patient is an infant girl who presented with cough, nasal congestion, and decreased oral intake with vomiting. She was well until 1 week prior to presentation when she developed a cough and congestion. She then developed decreased oral intake and vomiting. She had emesis 4 times in one day, and most were post-tussive. She also had a decreased number of wet diapers. They had been using Albuterol for the cough at home. She continued to vomit on the day of presentation, so she was brought to the emergency department for evaluation.
In the emergency department, her temperature was 99.7F., and her pulse was 131 beats per minute (bpm). On examination, she had dry mucous membranes and nasal congestion. Laboratory values were obtained which were significant for a bicarbonate of 18. A viral respiratory swab revealed Coronavirus as well as Influenza Type A. An abdominal ultrasound was obtained which was normal but the appendix was not identified. An intravenous line was attempted, but was not able to be placed, and she took 10 ounces of formula. She was subsequently admitted for further management of dehydration.
In the hospital, she received continued hydration, with a plan for 1 ounce per hour of oral fluids and intravenous fluids if not tolerated, and Zofran as needed. She initially tolerated oral intake, but then vomited twice and was started on intravenous fluids at 1.5 times maintenance. She was also given Dexamethasone, as well as racemic Epinephrine as needed. Her vomiting had resolved, she was tolerating oral intake, and was felt to be stable for discharge to home with follow up as an outpatient.
The inpatient hospital admission is under review for medical necessity.

I overturn, in whole, the health plan's determination of medical necessity.

Yes, the requested health service/treatment of an inpatient hospital admission was medically necessary for this patient.
This is a young infant who presented with vomiting and decreased oral intake in the context of a viral illness. She was felt to be dehydrated at the time of presentation and had a low bicarbonate level of 18. She required hospital admission to attempt refeeding and to provide intravenous fluids in order to maintain her hydration status, along with close monitoring with additional treatments as needed.
Indications for hospitalization for intravenous therapy for young children include failure of oral replacement therapy to provide adequate rehydration (e.g., persistent vomiting). While this patient was able to drink in the emergency department, she was felt to be dehydrated and continued to vomit after admission. She was therefore unable to adequately rehydrate without intravenous fluids and required close monitoring to ensure an appropriate clinical response.
According to the Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care Guidelines, 26th Edition, Vomiting, Pediatric, a hospital admission is indicated for patients who have vomiting with metabolic derangement, vomiting that is severe or persistent, and an inability to maintain oral hydration. This patient had persistent vomiting and was felt to be dehydrated based on physical examination as well as a low bicarbonate level. In the hospital, she developed vomiting after feeds and required intravenous fluids. She therefore required admission for ongoing treatment with intravenous fluids, along with appropriate monitoring for potential deterioration of clinical status.