Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Viral Gastroenteritis

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient is a female with a past medical history notable for eczema and recent rhino/enterovirus upper respiratory tract infection with dehydration that presented to the Emergency Department for assessment and management of 1 day of watery, non-bloody stools and non-bloody, non-bilious vomiting.  Her mother notes irritability, fatigue and poor intake of solids but was drinking.  There was no associated fever, rashes, distention, low urine output or weight loss.  Of note the patient had been discharged after a 2-day admission the day prior to this presentation. 
  
This child appears to have had viral gastroenteritis with loose stools, self-limited vomiting and minimal dehydration that responded to modest intravenous fluid repletion while in the Emergency Department.  The decision to admit her came after she demonstrated a successful oral challenge after a single normal saline bolus and one dose of Zofran, but refused to take additional volume.  In accordance with a review of the approach to acute viral gastroenteritis in children in resource-rich countries 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.   She did not meet any of these criteria to merit the inpatient setting. Her vomiting and loose stool at home prior to anti-emetics that never recurred clearly does not equate to intractable vomiting as stated in the appeal.  In fact, her vomiting never recurred during the admission and no additional anti-emetics were required.
 
In regards to her volume status a second review of dehydration in children discusses the elements to assess the degree of dehydration. Uptodate.

The documentation of this child's appearance and vitals would indicate minimal dehydration that resolved by the time of the decision to admit to the hospital.  A venous lactate of 2.2 is insufficient to estimate her volume status.  Her hypoglycemia resolved with supplementation. After bolus fluid resuscitation in the Emergency Department, anti-emetics and observation the child could have avoided an unnecessary acute care admission.  Clearly the Zofran was sufficient as she was able to tolerate fluids in the Emergency Department and a regular diet after admission.  After a brief period of observation this patient could have been safely discharged with outpatient follow-up.  She actually received no acute care after admission to merit reimbursement at that level except for continued intravenous fluids despite tolerating feeds without issue once permitted. 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. This decision was rendered based on review of the hospital record and the reviews from Uptodate summarizing the approach to nausea/vomiting and dehydration in children in cited above.

Uphold denial of coverage for acute inpatient admission. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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