Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dehydration

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient has a benign past medical history that was brought into the Emergency Department (ED) for assessment and management of fever, nasal congestion, and coughing for four days associated with intermittent nose bleeds, eye discharge and non-bloody, non-bilious vomiting x (times) 4 the day of presentation (3 episodes were post-tussive and one with eating). His urine output was decreased to once a day and his appetite was decreased as well. There was no associated GI (gastrointestinal) bleeding, diarrhea, weight loss or dysuria. The patient was seen by his provider the day before and started on Tamiflu. He was taking 90mg (milligrams) of Motrin up to 4 times per day for fevers while at home. The patient's vitals on arrival were notable for HR (heart rate)165 Temp 104.7 Fahrenheit, RR (respiration rate) 30, BP (blood pressure) 92/45 and room air oxygen saturation of 97% (percent). Admitting weight was 23.3 kilograms and height was 111 centimeters. Physical exam showed a sleepy but arousable well-appearing, non-toxic male. He had nasal congestion, tachy mucus membranes with normal capillary refill and normal skin turgor. Lungs were clear with normal effort. Cardiac exam was notable for tachycardia and an intermittent heart murmur (likely flow murmur). Abdomen exam was soft. There was no associated pain, organomegaly, distension, rebound, guarding or masses.
 
This child appears to have self-limited vomiting with mild dehydration that resolved by the time of admission to the inpatient setting associated with an upper respiratory viral infection with parainfluenza. He did not appear significantly dehydrated and did not have severe intractable vomiting as stated in the appeal.  In accordance with a review of the approach to nausea and vomiting in infants and children from UptoDate (see attached pdf file) 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. His blood pressure was normal for age and his tachycardia was related to fever rather than sepsis or dehydration. Unfortunately, he was receiving only small doses of Motrin that failed to suppress his fevers. Refusal to drink in the ED does not constitute oral rehydration intolerance and in fact he drank 360cc (cubic centimeters) the day he was transferred to the inpatient setting. Once admitted, he vomited once. 
 
The documentation of this child's appearance and vitals would indicate mild dehydration on presentation that resolved with modest intravenous resuscitation. His weight change after rehydration was 0.1 kilograms. After an evaluation excluded dangerous conditions, he could have been observed in the Emergency Department and safely discharged on oral fluids with outpatient follow-up. He received no acute care after admission to merit reimbursement at that level. Whether he had pneumonia is questionable and he was treated late in the admission with an oral agent.  Regarding the acute inpatient admission, the determination by the carrier that the admission was not medically necessary was correctly applied, objective, clinical 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 nausea and vomiting in children and dehydration in children in cited above.

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