Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Viral Gastroenteritis.

Treatment: Acute inpatient admission.

The insurer denied coverage for acute inpatient admission.

The denial is upheld.

This patient had a past medical history notable for 35-week gestation that was brought in by ambulance to the Emergency Department for assessment and management of non-bloody, non-bilous vomiting seven times associated with diarrhea two to eight times, decreased urine output and presumed abdominal pain. There was no associated fever, bleeding, weight loss or dysuria. The patient's vitals on arrival were notable for heart rate (HR) 120, Temperature 97.2, respiratory rate (RR) 28, Blood pressure (BP) 99/55 and room air oxygen saturation of 100% (percent). Admitting weight was 10.7 kilograms. Physical exam showed an awake and alert male in no acute distress. He had moist mucus membranes with normal capillary refill and normal skin turgor. Lungs were clear with normal effort. Cardiac exam was unremarkable. Abdomen exam was soft with diffuse tenderness to palpation. There were no associated organomegaly, distension, rebound, guarding or masses. Imaging included an abdominal x-ray at 10:03 that was normal, an abdominal sonogram that was normal (appendix not seen) and an abdominal computed tomography (CT) scan that showed mild left hydronephrosis without pyelonephritis and a normal appendix.  He received two 100 cc (cubic centimeters) boluses of normal saline followed by D[dextrose]5 normal saline at 42 cc/hour. In addition, he received intravenous (IV) Zofran 1 milligram (mg). He refused to drink oral contrast that was administered via nasogastric tube. Repeat laboratories showed a potassium 4.3 and lactate 1.35. The decision to admit him to the inpatient service for vomiting, diarrhea, dehydration, leukocytosis and observation occurred. He remained afebrile throughout the short admission. He had no further vomiting during his stay and passed 2 pasty stools. He received no pain medications, antibiotics, antipyretics or additional anti-nausea agents. He tolerated a normal toddler diet since admission. Additional laboratories showed sodium 139, potassium 4.7, bicarbonate 25, BUN 8, creatinine 0.28, lactate, white blood cell 8.8 without a left shift (neutrophils 58.4%), hemoglobin 10.9 and platelet 284.  He was discharged home for outpatient follow-up.
 
This child appears to have self-limited viral gastroenteritis with mild dehydration that resolved by the time of admission to the inpatient setting. He did not appear dehydrated as stated in the appeal and had no red flags to suggest a serious condition.  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. He did not meet any of these criteria to merit the inpatient setting. The evaluation performed prior to admission excluded serious possible causes of his symptoms. His pain was never significant and went untreated. Once admitted his vomiting had already stopped and his diarrhea did not recur (clearly not persistent). His repeat electrolytes prior to admission had normalized and his refusal to drink oral contrast did not constitute a failure of oral rehydration.
 
The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for acute inpatient admission is upheld. Medical Necessity is not substantiated.