Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infection In The Bowel/Stool (campylobacter).
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male child with a medical history significant for peanut allergy and eczema that presented to the ED with persistent symptoms of gastroenteritis, refusing to drink, and complaining of abdominal pain. He had been seen in the ED two days prior, diagnosed with gastroenteritis, and discharged home with Zofran. Since that time, he was refusing to eat or drink because of abdominal pain and had not urinated for 24 hours. He was no longer febrile. 

Vital signs included temperature 37.2, heart rate 101, respiratory rate 24, and blood pressure 103/70. The examination was significant for no distress, moist mucous membranes, regular heart rate and rhythm, normoactive bowel sounds, no distention, no guarding, no rebound, and a non-focal neurologic exam. Per the history and physical (H&P), additional physical exam findings in the ED included cracked lips, tacky tongue, and mildly delayed capillary refill. Laboratory evaluation was unremarkable. The patient was treated with a normal saline bolus and Pepcid. He was re-evaluated every one to two hours. His abdomen remained soft and non-tender the entire time, but he refused to drink anything. An abdominal ultrasound was obtained to rule out intussusception and was negative. 

Because he refused to drink for the duration of his time in observation in the ED, he was admitted for further management of mild dehydration and oral intolerance secondary to gastroenteritis. Admission orders included 1.5 maintenance intravenous (IV) fluids, gastrointestinal (GI) polymerase chain reaction (PCR), strict in/out measurements, and advancing diet as tolerated. The GI PCR returned positive for campylobacter. The patient was treated with another IV fluid bolus following admission. The following day the patient continued to have frequent loose stools. His appetite and intake remained poor, and he complained of abdominal pain with stooling. Repeat lab studies remained unremarkable. IV fluids were weaned to maintenance. Antibiotics were deemed not indicated because he did not meet the criteria for severe infection. He had a low-grade fever overnight. He was having fewer episodes of diarrhea but was still refusing oral intake. His IV fluids have discontinued the hope of encouraging oral intake. He was given a goal of oral intake in order to go home, which he met. He was deemed stable for discharge with instructions on maintaining hydration.

Yes, the proposed inpatient admission was medically necessary.

Acute gastroenteritis is a major problem worldwide, representing one of the leading causes of morbidity and mortality in children. There are an estimated 2.5 million deaths each year attributable to gastroenteritis in children under the age of five years. Most cases are caused by viruses, are self-limited, and require supportive treatment. According to the World Health Organization, oral rehydration therapy is the treatment of choice, particularly where diarrhea is a prominent feature, and dehydration is mild to moderate. Intravenous rehydration is indicated when oral rehydration fails or when output is excessive. Output (vomiting, diarrhea) limits the success of oral rehydration, prompting the use of anti-emetic medications. 

According to a national surveillance system maintained by the Centers for Disease Control (CDC), the leading pathogens for acute diarrheal illness included Norovirus and Salmonella enterica, with Norovirus and the more likely cause of illness and Salmonella being the more likely cause of hospitalization. Prior to vaccination, rotavirus was the most common pathogen in young children. The most common bacterial pathogens include Salmonella enterica, Campylobacter, Shigella, Yersinia, and E. coli. Avoiding dehydration or treating it once it occurs is the mainstay of management. Increased resistance to antimicrobials and the risk of worsening illness may result from the use of antimicrobial and antimotility agents, respectively.

This young child presented to the ED with signs and symptoms consistent with acute viral gastroenteritis was prescribed Zofran for vomiting and discharged home. He was brought back two days later because of ongoing frequent diarrhea, abdominal pain, and refusal to drink. He was found to be mildly dehydrated on the exam. He was treated with IV fluids in the ED but refused to eat or drink because of abdominal pain. He remained in observation for a number of hours but was unable to drink. He was admitted appropriately for the management of dehydration. He had failed outpatient management at home and management in the ED. The resultant hospital stay was medically necessary and appropriate.