Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dehydration.

Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This is a pediatric patient with a past medical history of asthma and recently diagnosed strep pharyngitis treated with Cefdinir. The patient was transferred to the Emergency Department (ED) from Urgent Care for assessment and management of intermittent abdominal pain and decreased oral intake for 1 week, fever, wheezing and low oxygen saturation [92 percent (%) on room air]. The patient's vitals on arrival were notable for heart rate 148, blood pressure 98/54, temperature 98.2 degrees Fahrenheit, respiratory rate 24 and room air oxygen saturation of 96%. Admitting weight was 14.6 kilograms. Physical exam showed a tired child in no apparent distress. The patient had moist mucus membranes, mild throat erythema without exudate and normal capillary refill (less than 2 seconds). Lungs were clear with mild crackles with normal effort. Abdomen exam was soft with mild diffuse tenderness. Admitting laboratories were notable for lactate 4.2. Chest X-ray showed left lower lobe atelectasis. The patient received an intravenous (IV) normal saline bolus followed by Dextrose 5% normal saline at maintenance. The patient received IV doses of Toradol, morphine and Zofran. Nasal viral washings were positive for human metapneumovirus. There was no vomiting or pain noted after admission and the patient tolerated liquids well. The patient did not require supplemental oxygen. The antibiotics were changed from Cefdinir to Zithromax to cover atypical pneumonia and the child was discharged home for outpatient follow-up.
  
This child appears to have an acute viral process with human metapneumovirus, and intermittent abdominal pain likely related to coughing or intermittent intussusception without obstruction that resolved by the time of admission to the inpatient setting. According to UpToDate the reasons to admit such an individual would include signs of significant dehydration poorly responsive to intravenous hydration in the ED, 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. The patient did not meet any of these criteria. At arrival, the patient did not appear significantly dehydrated nor were there significant respiratory symptoms. The patient demonstrated the ability to tolerate oral rehydration upon arrival to the inpatient floor. 
 
Per UpToDate, degree of dehydration-Fluid repletion guidelines for children with gastroenteritis by the American Academy of Pediatrics, Centers for Disease Control, and the World Health Organization are based upon the degree of volume depletion. Volume depletion is most objectively measured as a change in weight from baseline. Acute loss of body weight reflects the loss of fluid, not lean body mass.

The documentation of this child's appearance and vitals at presentation would indicate no or minimal dehydration that resolved with modest intravenous resuscitation. The laboratory abnormalities were not critical and would be expected to correct with fluid resuscitation followed by oral rehydration therapy. The elevated lactate level did not represent poor tissue perfusion or entrapped bowel from intermittent intussusception. After admission, the patient was observed with both modest intravenous and oral fluids, and safely discharged on oral fluids with outpatient follow-up. Oral rehydration with or without solids could have been administered as an outpatient after demonstration of the ability to rehydrate enterally in the ED. 

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 inpatient hospital admission is not substantiated.