Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

This is a female with a past medical history notable for incomplete trisomy 16, developmental delay, and horseshoe kidney that was referred to the Emergency Department for assessment and management of non-bilious, non-bloody vomiting for one day, lethargy, decreased oral intake, and possible abdominal pain. Her urine output was decreased. There was no associated fever, gastrointestinal (GI) bleeding, diarrhea, weight loss, or dysuria. The patient was seen by her provider and her white blood count was elevated, leading to the referral. Physical exam showed a sleepy but arousable ill-appearing, pale, diaphoretic female. She had moist mucus membranes with delayed capillary refill and decreased skin turgor. Lungs were clear with normal effort. Cardiac exam was notable for a systolic heart murmur. Abdomen exam was soft. There was no associated pain, organomegaly, distension, rebound, guarding, or masses. There was no rectal exam reported. 

This child appears to have self-limited vomiting with mild dehydration that resolved by the time of admission to the inpatient setting associated with an unrecognized foreign body ingestion. She did appear significantly dehydrated on presentation that improved with modest fluid resuscitation. She did not have severe intractable vomiting as stated in the appeal. In accordance with a review of the approach to nausea and vomiting in infants and 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, significant weight loss, profound lethargy, hemodynamic instability, significant electrolyte imbalance, demonstrated oral hydration intolerance to oral challenge, 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. She did not meet any of these criteria to merit the inpatient setting. Her blood pressure was normal for age and her heart rate on discharge was higher than on presentation. Although she did have some abdominal discomfort during the admission, she did not require pain medications. She never had bowel obstruction suspected by imaging or physical exam as stated in the appeal and there were no surgical indications as noted in the surgical and gastroenterology consults. 
 
A second reason given to justify the inpatient setting was significant dehydration. In regard to her volume status, another article of dehydration in children from UptoDate was reviewed. The documentation of this child's appearance and vitals would indicate mild/moderate dehydration on presentation that resolved with modest intravenous resuscitation within hours of her arrival. After an evaluation excluded dangerous conditions, she was merely observed with multiple negative assessments and safely discharged on oral fluids with outpatient follow-up. She received no acute care after admission to merit reimbursement at that level. Her leukocytosis with a normal C-reactive protein (CRP) did not suggest a bacterial process and no antibiotics were administered. 

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.