Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nausea, vomiting. 
Treatment: Inpatient Hospital Admission. 

The insurer denied the Inpatient Hospital Admission. 
The denial is overturned. 

The patient is a male who presented with nausea, emesis, and diarrhea. He was well until approximately a week prior to presentation when he developed emesis. He had abdominal pain any time he tried to eat, and within a few minutes he would vomit. His mother described the emesis as green-yellow in color, and stated that his abdominal pain was so severe at times that he would 'pass out'. He then developed diarrhea and subjective fevers. He was seen by his primary doctor who prescribed oral Zofran, but he was still unable to tolerate oral intake and had decreased urine output, so he was brought to the emergency department for evaluation. Of note, he had eaten peanut butter that had been recalled around the time that his symptoms began. 

In the emergency department he was found to have a temperature of 100 Fahrenheit (F) and a heart rate of 132 beats per minute (bpm), and on physical examination he had dry lips. Laboratory values revealed a bicarbonate level of 17, and a blood culture was sent due to concern for possible Salmonella bacteremia. An abdominal x-ray was also obtained and was normal. He was given two boluses of normal saline. An oral trial was then attempted but was unsuccessful due to vomiting. He was therefore admitted to the hospital for continued treatment and monitoring. 

In the hospital he was given intravenous fluids and was monitored. His oral intake improved over time, and he was able to tolerate a clear liquid diet. He was given Zofran as needed for nausea and was able to advance to solid foods. Stool cultures and the blood culture were negative. He was felt to be stable for discharge to home with follow up as an outpatient. 

The medical necessity for the inpatient hospital admission is the subject under review. 

The health plan's determination is overturned. 

The requested Inpatient Hospital Admission was medically necessary for this patient. This is a patient who presented with vomiting, diarrhea, and decreased oral intake. He had symptoms for a week and was not improving. At the time of presentation, he was tachycardic with dry lips, and his laboratory evaluation indicated dehydration with a low bicarbonate of 17. He was given appropriate treatments in the emergency department including intravenous fluids and Zofran, but he was still unable to tolerate oral fluids. There was also concern for possible Salmonella infection due to exposure to recalled peanut butter. He therefore required inpatient hospitalization for continued intravenous fluids, continuous monitoring, and additional evaluation and treatment as needed.
Children with dehydration require intravenous therapy when they are unable to take oral replacement therapy (ORT) or when ORT would not provide adequate rehydration. This patient was dehydrated at the time of presentation with over a week of symptoms and both outpatient and emergency department treatment, and he continued to vomit. He therefore required inpatient admission for continued intravenous treatment and close monitoring. 
The decision making at the time of admission for this patient was consistent with his age, the presence of vomiting and diarrhea with dehydration that persisted despite appropriate treatment as an outpatient and in the emergency, department setting, and the need for continued intravenous treatments along with close monitoring for potential deterioration of clinical status.