Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vomiting, cough, sore throat, arthralgias
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male child with medical history significant for autism spectrum disorder, mild to moderate developmental delay, hypothyroidism, obstructive sleep apnea, recurrent aspiration pneumonia, and seizure disorder treated with ketogenic diet and Epidiolex that presented to the emergency department (ED) with three-day history of cough, one-day history of sore throat and knee/ankle pain, and same-day history of post-tussive emesis followed by approximately thirty episodes of bright yellow emesis with retching over a two-hour time period. The patient was subsequently able to tolerate his medications. He had no seizure activity. The patient's father also had arthralgias and fever. 

Vital signs included temperature 37, heart rate 140, respiratory rate 32, and blood pressure 162/89. Oxygen saturation was 92% in room air. Examination was significant for no acute distress, moist mucous membranes, tachycardia, clear lungs without wheezing, benign abdomen, and non-focal neurologic exam. Laboratory evaluation revealed positive respiratory syncytial virus (RSV) and valproic acid level subtherapeutic at 35. Chest x-ray revealed small airways disease and moderate colonic stool. He was treated with intravenous (IV) fluids, ceftriaxone, and Zofran and offered an oral challenge which he failed. He was unable to tolerate anything by mouth. Pediatric Neurology was consulted with recommendations to administer valproate IV and return to oral valproate and Epidiolex once vomiting had resolved. Because of the persistent vomiting, his case was also discussed with Pediatric Surgery. The patient was admitted for further management and failed oral challenge. 

Admission orders included home seizure management, continuous pulse oximetry, follow-up on cultures, home supplementation, normal saline at maintenance, ketogenic diet, and follow-up cultures. Overnight, the mother also developed vomiting and was sent to the ED. The child desaturated overnight to 85% but was unable to tolerate the nasal cannula so was taken off of continuous pulse oximetry. He had no further vomiting and was able to tolerate his oral diet with good urine output. He was subsequently deemed stable for discharge home. 

Yes, the proposed inpatient admission was medically necessary.

This male child with complex seizure disorder requiring treatment with ketogenic diet, Epidiolex, and conventional anti-convulsant medications, as well as autism spectrum disorder, obstructive sleep apnea, and recurrent aspiration pneumonia presented to the ED with mild respiratory symptoms and refractory recurrent vomiting. He failed an oral challenge in the ED after receiving fluids and Zofran, necessitating admission for ongoing management. While his symptoms improved sufficiently by the next day to allow for discharge home, the complexity of his medical conditions, the desaturations he experienced while sleeping, and the inexplicable nature of his recurrent vomiting supported acute inpatient admission. Lower level of care would not have been sufficient to provide for his complex needs.