Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Abdominal/Stomach Pain.
Treatment: Inpatient Admission.

The health plan denied the requested inpatient admission.  The health plan's determination is overturned.

The patient is a female adolescent with a medical history significant for asthma who presented to the emergency department (ED) with a four-day history of abdominal pain, nausea, vomiting, lightheadedness, and chills. She had a Covid19 infection six weeks prior and had fully recovered. She went to the ED and was given Zofran and another medication. The pain worsened, she was unable to eat, and she had pain with urination. She was noted to have mottled skin, tachycardia, and no palpable blood pressure. The initial set of vital signs included a temperature of 97.2., a heart rate of 121 beats per minute (bpm), and 98% oxygen saturation on room air. Examination was significant for ill appearance, mottling of the abdomen and extremities, shaking chills, pallor, normal-appearing oral mucosa, clear lungs, poor capillary refill, cold extremities, and decreased skin turgor. The first blood pressure was 60 millimeters of mercury (mmHg) systolic by a manual cuff. She was treated with antibiotics empirically and aggressive fluid resuscitation with two liters. Her blood pressure was measured at 88/50 mmHg. Another facility's Pediatric Intensive Care Unit (PICU) was contacted for transfer with a direct admission. She was accepted for higher level of care for possible MIS-C (multisystem inflammatory syndrome). 

Admission orders included follow-up cultures, holding antibiotics, pediatric cardiology consultation due to elevated cardiac enzymes, formal echocardiogram, sequential stockings for deep vein thrombosis (DVT) prophylaxis, intravenous (IV) fluids, antipyretics, and pain control as needed. Per pediatric cardiology, the echocardiogram was within normal limits, recommendations for follow-up if MIS-C was diagnosed, and consideration for other inflammatory conditions that would not require aspirin. Subsequently, notes indicated that she did not meet MIS-C criteria and would not require activity restrictions. She had remained stable overnight, with no fevers, resolution of nausea and vomiting, and no abdominal pain. She had developed diarrhea. An abdominal ultrasound did not reveal acute pathology. Diet was advanced and the central line was removed. She was transferred to the floor following resolution of hypotension. She remained stable with resolution of symptoms. She was deemed stable for discharge to follow-up with her primary care practitioner.

This young woman presented with a recent history of Covid infection and new-onset abdominal pain, nausea and vomiting, and fever. She was in shock upon arrival, requiring aggressive fluid resuscitation. Despite administration of two liters of fluids, she remained hypotensive, treated with norepinephrine infusion. She was admitted to the PICU where she underwent comprehensive evaluation including additional lab studies, ultrasound, cardiology consultation. Upon completion of the diagnostic work-up, she did not meet criteria for MIS-C. She recovered rapidly, was able to wean from pressors, advance to a regular diet, and transfer to the floor for final monitoring. This level of care is most consistent with acute inpatient management. A lower level of care would not have been appropriate in this case.