Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Viral gastroenteritis. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

Patient is a child with a benign past medical history that presented to the Emergency Department (ED) complaining of periumbilical abdominal pain without radiation, intermittent non-bloody non-bilious vomiting x 2 days, low grade fever 100.5, and decreased oral intake. There was no associated cough, rhinorrhea, congestion, wheezing, shortness of breath, weight loss, decreased urine output or dysuria. There were no sick contacts. Of note the patient presented to the local provider and received Zofran x 1 with improvement in the vomiting. The patient's vitals were notable for blood pressure (BP) 109/72, heart rate (HR) 100, Temperature 98 Fahrenheit, respiratory rate (RR) 25 and room air oxygen saturation of 100%. Physical exam showed an awake and alert patient in no apparent distress. The patient had normal mucus membranes with normal cap refill. Lungs were clear with normal effort. Cardiac exam was unremarkable. Abdomen exam was soft and flat. There was no associated pain, organomegaly, distension, rebound, guarding or masses. There was no rectal exam reported. No imaging was performed. After refusing to drink and seeing the low blood sugar and urine ketones, the decision to admit the patient to the inpatient unit for dehydration and persistent hypoglycemia in the setting of acute gastroenteritis. The patient was transferred by ambulance for admission. The repeat blood sugar was 62 leading to a 20 milliliter (mL) bolus of Dextrose 50% (D50) resolution of low sugars. Once admitted the patient received intravenous fluid with oral fluids as tolerated. The patient was offered a regular diet and tolerated it within hours of transfer without further vomiting. Repeat labs in the morning of 2/18 remained normal notable for sodium 140, potassium 4.3, bicarbonate 21.5, BUN 7, creatinine 0.47 and glucose 73. No additional anti-emetics were needed. 
 
The insurer is denying the acute inpatient admission as not meeting medical necessity criteria for acute inpatient admission by lack of serious findings in the patient's vitals, labs, physical exam and history to meet Millman Care Guideline 26th Edition standards for Vomiting, Pediatric ORG: P-371 (ISC) for the acute inpatient setting. 
 
The documentation of this child's appearance and vitals would indicate minimal to no dehydration on presentation that resolved with modest fluid resuscitation and maintenance fluids. The patient's documented heart rate upon arrival to the emergency department (ED) was nearly the same as the discharge heart rate. Intravenous dextrose and fluid to clear ketones as well as oral Zofran would have been enough to permit adequate oral rehydration as per standard of care. The patient appeared to be admitted for observation and the fact that the patient was transferred from one site to another for care. The patient actually never received any acute care after the decision to admit to the inpatient setting to merit reimbursement at this level. In regard to the acute inpatient admission, the determination by the carrier that the admission was not medically necessary was correctly applied, objective, clinically valid, compatible with established principles of health care and flexible enough to permit justified variation. This decision was rendered based on review of the hospital record and the attached reviews from UpToDate summarizing the approach to acute viral gastroenteritis in children and dehydration in children in cited above. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is not substantiated.