Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypoglycemia.
Treatment: Inpatient hospital stay.
The insurer is denied coverage for inpatient hospital stay.
The denial is upheld. 
This is a male patient with a past medical history of Meckel's diverticulum status post resection and an omphalomesenteric duct cyst. He presented to the Emergency Department with complaints of several episodes of vomiting and bloody diarrhea. It was reported that the patient had decreased oral intake, decreased urine output and low-grade fever (100F).There was no associated pain or weight loss. The patient's presenting vital signs were: heart rate of 114, a temperature of 98.2F, a respiratory rate of 22, blood pressure of 102/58 and a room air oxygen saturation of 100%.  A physical exam showed a well -developed, well-nourished male in no distress who was awake and alert. He appeared mildly dehydrated with normal capillary refill; his lungs were clear. Cardiac exam was unremarkable. Abdomen exam was soft with normal bowels sounds. Admitting laboratories were notable for sodium of 135, potassium of 3.4, a bicarbonate level of 16, blood urea nitrogen (BUN) of 15, a creatinine 0.39 and glucose of 74. A dextrose (d)-stick showed a glucose of 66. He received intravenous fluid bolus. He was admitted to the hospital for hypoglycemia. A follow-up d-stick showed a glucose of 63 leading to a second D10 W bolus. After a period of medical stability he was discharged home the same day for outpatient follow-up. 

Nausea and vomiting in 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, hemodynamic instability, significant electrolyte imbalance, demonstrated oral hydration intolerance to oral challenge (after treatment with anti-emetics and fluids), 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. 

1)	Mild dehydration (3 to 5 percent volume loss) - A history of fluid losses may be the sole finding, as clinical signs may be absent or minimal. Such patients may have a reduction in urine output, but this may not be appreciated.

2)	  Moderate dehydration (6 to 9 percent volume loss) - Signs and symptoms are now apparent and can include the following: tachycardia, orthostatic falls in blood pressure, especially with orthostatic changes, decreased skin turgor, dry mucous membranes, irritability, decreased peripheral perfusion with a delay in capillary refill between two and three seconds, and deep respirations with or without an increase in respiratory rate. There may be a history of reduction in urine output and decreased tearing and, in infants; an open fontanels will be sunken on physical examination.
 
The most useful clinical signs that predicted 5 percent hypovolemia in children were delayed capillary refill time, reduced skin turgor, and deep respirations with or without an increase in absolute respiratory rate. A combination of signs and symptoms was better than an individual finding at predicting hypovolemia.

3)	  Severe dehydration (>=10 percent volume loss) - Such children typically have a near-shock presentation as manifested by hypotension, decreased peripheral perfusion with a capillary refill of greater than three seconds, cool and mottled extremities, lethargy, and deep respirations with an increase in rate. Severe hypovolemia requires immediate aggressive isotonic fluid resuscitation to restore the effective circulating volume [ECV] and prevent ischemic tissue injury."

The insurer acted reasonably, with sound medical judgment, and in the patient's best interest. 

Based on the above, the medical necessity for the inpatient hospital stay is not substantiated. The insurer's denial is upheld.