Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Viral gastroenteritis with self-limiting vomiting

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial is upheld.

The patient is a female child with a past medical history notable for asthma who presented to the Emergency Department (ED) for assessment and management of 4 hours of non-bloody, non-bilious vomiting (8 episodes) since the prior evening. The patient's mother noted that the patient had decreased oral intake, crankiness, paleness and no wet diapers. The mother was being treated for Influenza. The patient had no associated fever, upper respiratory infection (URI) symptoms, diarrhea, rashes, distention, or weight loss. The patient's vital signs on arrival were notable for heart rate of 118, temperature of 98.6 F, respiratory rate of 24, blood pressure of 100/68, and oxygen saturation of 96% on room air. The patient's admitting weight was 14.6 kilograms and height was 99 centimeters. The patient's physical exam showed a well-developed, well-nourished female. The patient was awake and alert. The patient had moist mucus membranes with normal capillary refill. No urinalysis was submitted for review. The patient's nasal viral washings were negative for Influenza. The patient's imaging included an abdominal flat plate that showed a distended stomach, abundant stool and a non-obstructive gas pattern. The patient received two 20cc/kg (280mL) normal saline boluses followed by D5 normal saline @ 70cc/hour. In addition, the patient received intravenous Zofran for her last vomiting episode. The decision was made to admit the patient to the inpatient service for observation for viral gastroenteritis and intractable vomiting. No vomiting recurred during the inpatient stay. The patient was given a glycerin suppository. 

Based on the review of the medical record and literature, this patient appeared to have viral gastroenteritis with self-limited vomiting and minimal to mild dehydration that responded well to intravenous fluid repletion while in the Emergency Department. The decision to admit the patient came after an episode of vomiting following an oral challenge after 2 normal saline boluses before Zofran was administered. 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. In this
case, this patient did not meet any of these clinical criteria to merit inpatient admission. The patient's vomiting episode prompting admission was prior to administering anti-emetics. Thus, it does not equate to intractable vomiting. In fact, the patient's vomiting never recurred after being given anti-emetic and did not require additional anti-emetic medication during the inpatient stay.

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

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial should be upheld.