Appeal type: Medical necessity
Decision: Upheld

Diagnosis: hypovolemia, Respiratory Syncytial Virus, rotovirus

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

The patient was a child that presented to the Emergency Department for non-bloody diarrhea x 4 days, tactile fever x 2 days (responsive to Tylenol), non-bloody vomiting x 1 (two days earlier), decreased oral intake and decreased urine output. The patient also had some mild congestion and cough without shortness of breath. The patient's vitals were notable for heart rate 138, temperature 102.4 degrees Fahrenheit, respiratory rate 36, and room air oxygen saturation of 99%. The child had moist mucus membranes with normal cap refill. Respiratory viral panel was positive for Respiratory Syncytial Virus (RSV). The child's admitting weight was 12.6 kilograms (88th % for age) and the height was 88 centimeters (97th % for age). The child had tolerated 4 ounces of juice and 2-3 ounce of Pedialyte while in the ED. Once admitted the child was permitted a full fluid diet. The child did not vomit during the admission. The child continued to have loose stools without blood and a Gastrointestinal Polymerase Chain Reaction (PCR) was positive for Rotavirus A.
 
This child had viral gastroenteritis and RSV bronchiolitis with minimal respiratory symptoms and watery diarrhea. Although intake was overall decreased, the child was not significantly dehydrated (normal heart rate for age when not febrile, moist mucus membranes and normal capillary refill) that resolved after fluid repletion. The child was able to tolerate oral rehydration prior to admission to the inpatient unit. In accordance with a review of the approach to acute viral gastroenteritis in resource rich countries 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. The child did not manifest any of these criteria to merit care in an acute inpatient setting. 
 
In regard to the volume status, in a second review of dehydration in children from UpToDate, the following elements summarize the assessment of the 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. As a result, it is important to be as accurate as possible when assessing the degree of dehydration. Severe hypovolemia requires rapid isotonic fluid resuscitation, although oral rehydration may be sufficient for mild to moderate hypovolemia.

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; thus, a 2 kilograms (kg) weight loss should reflect the loss of two liters of fluid. In most cases, however, a previous recent weight is not available. As a result, a number of findings on physical examination coupled with the pertinent clinical history are used to help assess the severity of hypovolemia. These findings include the child's pulse, respiratory rate, blood pressure, skin turgor, peripheral perfusion (delayed capillary refill) and systemic signs such as increased thirst or lethargy, and changes in urine output.

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.