Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea and vomiting

Treatment is an acute inpatient admission

The insurer denied coverage for an acute inpatient admission
 
The denial is upheld

This is a pediatric patient with a past medical history notable for Angelman syndrome (developmental delays), eczema and constipation that presented to the Emergency Department for assessment and management of 1 week of known positive Respiratory Syncytial Virus (RSV), decreased oral intake, no urine output or stool for 1-day, acute onset of non-bilious vomiting for 3 hours, and fever. There was no associated gastrointestinal (GI) bleeding, sick contacts, weight loss or dysuria prior to presentation. The patient's initial vitals were notable for heart rate (HR) of 143, temperature of 99.2 degrees Fahrenheit, respiratory rate of 28 and room air oxygen saturation of 98%. Physical exam showed an awake and alert toddler in no apparent distress. The patient had normal mucus membranes, normal skin turgor and normal capillary refill. Lungs were clear with normal effort. The cardiac exam was unremarkable. The abdominal exam was soft. There was no associated pain, organomegaly (enlargement of organs), distension, rebound, guarding or masses. There was no rectal exam reported. While in the Emergency Department the patient vomited pink-tinged vomitus and some black specks repeatedly. Laboratories were notable for sodium 145, potassium 3.9, bicarbonate 20, blood urine nitrogen 22, creatinine 0.55, glucose 52, white blood cell 13.8 with a left shift (neutrophils 71%, no bands), hemoglobin 14.5, platelets 427, lipase 10 and an unremarkable liver panel. The respiratory pathogen panel was positive for RSV. 

The documentation of this patient's appearance and vitals would indicate mild volume depletion on presentation that resolved with modest resuscitation with a single 20 cubic centimeters per kilogram (cc/kg) normal saline bolus. After a single dose of Zofran the vomiting ceased, and the patient could have been hydrated intravenously for a short period and then converted to oral rehydration therapy as per standard of care and avoiding the short inpatient stay. Pink-tinged vomitus with some coffee grounds did not suggest significant active upper gastrointestinal bleeding that would merit the inpatient setting as stated in the appeal. In fact, no repeat laboratories were performed, no gastroenterology or surgery consult was requested, and no acid suppression was continued after discharge. The patient appeared to be admitted to observe her oral intake while receiving modest intravenous fluids and to see if gastrointestinal bleeding progressed. The patient was discharged within 24 hours of presentation. The determination by the carrier that the admission was not medically necessary was correctly applied, objective, clinically valid, compatible with established principles of healthcare 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 upper gastrointestinal bleeding in children cited above. The patient could have been treated in observation status. 

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 admission was not substantiated.