Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was upheld. 

This patient is a male child with a benign past medical history that presented to the Emergency Department for assessment of non-bilious, non-bloody vomiting x 4 days, abdominal cramping, watery non-bloody stool and tactile fever.  These symptoms were associated with runny nose and congestion and there was a sick contact.  There was no associated weight loss, dysuria, or bleeding.  Of note he was evaluated at an Urgent Care Center four days prior and prescribed Zofran twice daily (BID) but vomiting of solids continued.  The patient's vitals on arrival were notable for Heart Rate 118, Temperature 98 F, Respiratory Rate 30, Blood Pressure 124/82, and room air oxygen saturation of 98%.  His admitting weight was 14 kilograms.  His physical exam was notable for a well-developed, well-nourished male in no apparent distress.  He was awake and appropriate for age.  He had moist mucus membranes, normal cap refill and warm, dry skin. His lungs were clear.  His cardiac exam was unremarkable.  His abdominal exam was notable for normal bowel sounds and was soft.  There was no tenderness to palpation, organomegaly, distension, rebound, or guarding.  No rectal exam was noted. Initial laboratories were notable for sodium 128, BUN 7, creatinine 0.3, chloride 93, bicarbonate 23, glucose 88, white blood count 12 with left shift (81% neutrophils, 5% bands), hemoglobin 11.8 and platelets 399K.

The insurer is denying the acute inpatient admission as not meeting inpatient medical necessity criteria since he had stable vitals, physical exam and lab work, citing Milliman Care Guideline 23st Edition - Milliman Care Guidelines for Gastroenteritis, Diarrhea and Dehydration or Dysentery, Peds ORG-P-190.

This patient appeared to have viral gastroenteritis with fever, self-limited vomiting and intermittent abdominal cramping followed by watery diarrhea leading to minimal dehydration that resolved after adequate fluid resuscitation.  He was admitted despite tolerating an oral challenge.  After a single normal saline bolus his vomiting abated.

According to a review of the approach to nausea and vomiting in children by UpToDate (1) the reasons to admit such an individual to the acute care setting 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, poorly controlled pain with an oral pain medication regimen, concerning physical exam findings for a surgical process (bowel strangulation, appendicitis) or findings consistent with significant blood loss or bowel obstruction.  

This patient's condition did not meet any of these criteria.  His electrolyte abnormalities actually normalized on the same day as his presentation.  His change in physical exam noted in the late evening actually occurred after his admission and resolved without intervention.  This patient was noted to be irritable and ill appearing whenever he had fever but was otherwise well-appearing when fevers resolved. The criteria cited by the hospital suggested the need for hydration to address significant hyponatremic dehydration.  Actually, his laboratory studies, physical exam and urinalysis were more consistent with dilutional hyponatremia in the setting of excessive water intake (hyponatremia, very low urine specific gravity, moist mucus membranes and normal capillary refill).  

In conclusion, the acute inpatient admission is denied due to lack of medical necessity.  The determination by the carrier in regards to the denial of acute care admission 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 carrier's denial of coverage for the acute inpatient hospitalization is upheld.  The medical necessity is not substantiated.