Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Digestive System / Gastrointestinal
Treatment:  Inpatient Hospital

The patient is a male who presented with vomiting and dehydration.
He was well until the night prior to admission when he began to have multiple episodes of vomiting, as well as non-bloody diarrhea.  He also had subjective fever at that time and was complaining of abdominal pain.  He had a history of frequent urination for some time, but it had not been evaluated.  He continued to vomit on the day of admission and had vomited 3 times with "constant" passing of watery stools.  He was brought to the emergency department for evaluation and care.
On physical examination in the emergency department he was noted to be clinically dehydrated with dry mucous membranes and dry skin, as well as tachycardia.  He also had sunken eyes ,as well as a capillary refill greater than 5 seconds.  He had some tenderness in the periumbilical area with no rebound.  He was not circumcised.  Laboratory values were obtained, which were significant for an elevated white blood count of 17,000 with 85% neutrophils, and a low bicarbonate level of 19 milliequivalents (mEq) per liter and a low sodium of 131 millimoles (mmol) per liter.  His urine specific gravity was greater than 1.030 with large ketones noted.
He was diagnosed with gastroenteritis and dehydration.  He was given intravenous fluids as well as ondansetron.  However, he continued to have abdominal pain, as well as constant diarrhea in the emergency department, to the point of having incontinence.  Therefore, he was admitted for further treatment with intravenous fluids and cardiovascular monitoring.
Following admission, he was continued on intravenous fluids.  He was also given ampicillin due to his elevated white blood count and the development of bloody stools after admission.  A stool culture was sent.  An abdominal ultrasound was also obtained, which was normal.  He improved over time, was tolerating fluids, and was felt to be stable for discharge with follow-up as an outpatient.  The medical necessity for the inpatient stay is the subject under review.

The health plan's determination is upheld.

This is a young male who presented with severe diarrhea and vomiting.  He was having constant stools at the time of presentation and was unable to tolerate oral intake because of his vomiting.  He was noted to be clinically dehydrated, with dry mucous membranes and tachycardia.  He also had a prolonged capillary refill and sunken eyes.  He was also found to have abnormal laboratory values, with an elevated white blood count and left shift, a low bicarbonate and low sodium, and a very elevated urine specific gravity with ketones.  He required prompt initiation of intravenous fluids, as well as further evaluation.  In fact, his stools turned bloody raising concern for bacterial infection, and he required a stool culture, as well as an abdominal ultrasound; he was also given parenteral antibiotics.
The decision-making at the time of admission for this patient was consistent with his young age, the presence of significant and persistent diarrhea with vomiting, abdominal pain, an inability to maintain hydration orally, and the need for intravenous therapies, as well as close monitoring for potential deterioration of clinical status.