Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis. 
Treatment: Inpatient admission. 
The insurer denied coverage for an inpatient admission. 
The denial is upheld. 

The patient has a past medical history notable for depression and syncope that presented to the Emergency Department for assessment and management of non-bloody, non-bilious emesis x 4 since midnight, epigastric crampy abdominal pain and non-bloody loose stool x 2. There was no associated fever, orthostatic symptoms, GI (gastrointestinal) bleeding, known weight loss or dysuria. The patient's vitals on arrival were notable for Heart Rate 97 Temperature 97.9 F (Fahrenheit), Respiratory Rate 18, Blood Pressure 95/64 and room air oxygen saturation of 99%. Admitting weight was 42.2 kilograms and height was 155.5 centimeters. Physical exam showed an alert female in no apparent distress. She was non-toxic appearing. She had moist mucus membranes with normal capillary refill (<2 seconds). Lungs were clear with normal effort. Cardiac exam was unremarkable. Abdomen exam was soft. There was no associated pain, organomegaly, distension, rebound, guarding or masses. There was no rectal exam reported. Admitting laboratories were notable for sodium 137, potassium 4.2, bicarbonate 22, BUN (blood urea nitrogen) 14, creatinine 0.82, glucose 116, white blood cell 13.4 with a left shift (neutrophils 90%), hemoglobin 13.4, platelet 213 and a normal liver profile. Urinalysis showed specific gravity 1.020/pH (potential of hydrogen) 6 and was dip + (positive) for trace protein and 3+ glucose. Nasal viral washings were negative for Influenza and Covid. Urine pregnancy test was negative. No Imaging was performed. She received Zofran 4mg (milligrams) SQ (subcutaneous) x 1, Pepcid 20mg PO (oral)x 1 at and a 20cc (cubic centimeters)/kg (kilograms) bolus of normal saline (844 cc). She was given apple juice and was about to be discharged but vomited again x 2. Her intravenous line was reinserted, and the decision was made to admit her for viral gastroenteritis and dehydration. She was given intravenous fluids x 6 hours then weaned. She was given a clear liquid diet. After admission vomiting and diarrhea did not recur. She was given a single dose of oral Tylenol and 2 intravenous doses of Pepcid. No additional anti-emetics were administered. No repeat laboratories were performed. She was discharged home for outpatient follow-up. 

The documentation of this teen's appearance and vitals would indicate minimal to no dehydration on presentation that certainly resolved with modest intravenous fluid resuscitation within hours of her arrival. Her laboratory abnormalities were not critical (elevated glucose and glucose in her urine) both not evaluated during the short admission.  She appeared to be admitted as a knee-jerk reaction to vomiting after oral apple juice as clearly documented in her plan of care. After admission she was merely observed with both intravenous and oral fluids, and safely discharged on oral fluids with outpatient follow-up. She actually received no acute care after admission to merit reimbursement at that level. In regards to the appeal citations, she met none of the Millman criteria for any of the categories cited. Oral rehydration could have been reattempted while still in the Emergency Department with additional observation to avoid an unnecessary short inpatient stay. In regards to 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. 
The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

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