Appeal type: Medical necessity
Decision: Overturned


Treatment: Inpatient hospital admission 

The insurer denied coverage for inpatient hospital admission.  The denial is reversed. 

This patient is a male with a history of pancreatitis.  The patient presented to the emergency room (ER) with two days history of abdominal pain and vomiting.  The patient's abdomen was soft, non-distended, with diffuse mild tenderness on exam; there was no rebound or guarding.  The patient's right upper quadrant ultrasound was normal.  The patient was given intravenous (IV) fluids, oral Zofran, Tylenol, Maalox, and Pepcid.  The patient initially reported feeling better, but then started vomiting while in the ER.  Intravenous (IV) Zofran and additional IV fluids were given.  The decision was made to admit the patient due to an inability to tolerate oral intake.  The patient was admitted to pediatrics and was treated with IV Zantac, IV Tylenol, and IV fluids.  The patient's symptoms improved, and he was able to tolerate a regular diet.  The patient was discharged to home.

The inpatient admission was medically necessary for this patient.  The patient presented to the hospital with severe abdominal pain and vomiting.  The patient's symptoms were suggestive of acute, infectious gastroenteritis.  The patient was unable to tolerate oral intake and continued vomiting despite the treatments received in the emergency room.  It would have been inappropriate to discharge this patient home because he was at a high risk for dehydration from his recurrent vomiting, and his inability to tolerate oral intake.  The patient needed intravenous fluids, an abdominal X-ray and close monitoring.

Although most cases of gastroenteritis do not require inpatient care, a small percentage of cases (such as this case) need inpatient care.  Per Banyai, K., et al. (2018), "For treatment of dehydration caused by gastroenteritis viruses, the administration of reduced-osmolality oral-rehydration solutions (5060 mmol/L sodium) is the first line of therapy.  Profuse vomiting, worsening dehydration with altered consciousness, or severe acidosis, hypovolemic shock, abdominal distension, and ileus are indications for intravenous rehydration."  Per Stuempfig, N. D et al (2019), "The treatment of viral gastroenteritis is based on symptomatic support [3][4].  The most important goal of treatment is to maintain hydration status and effectively counter fluid and electrolyte losses.  Fluid therapy is a fundamental part of treatment.  Intravenous fluids may be administered to those individuals who appear dehydrated or to those unable to tolerate oral fluids..."

Per Hartman S1. et al. (2019), "Acute gastroenteritis is defined as a diarrheal disease of rapid onset, with or without nausea, vomiting, fever, or abdominal pain.  In the United States, acute gastroenteritis accounts for 1.5 million office visits, 200,000 hospitalizations, and 300 deaths in children each year.  Evaluation of a child with acute gastroenteritis should include a recent history of fluid intake and output...  Hospitalization and intravenous fluids are recommended for children who do not respond to oral rehydration therapy plus an antiemetic and patients with severe dehydration (i.e., signs of shock or more than 10% dehydration).  Handwashing, breastfeeding, and rotavirus vaccination reduce the incidence of acute gastroenteritis in young children."                

Based on the review of the literature and this patient's clinical presentation, this patient met the clinical criteria for inpatient care due to the continuous vomiting and need for intravenous fluid hydration.  

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient.  The carrier's denial of coverage for the inpatient hospital admission is reversed.  The medical necessity is substantiated.