Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dehydration

Treatment: Inpatient Admission

The insurer denied the inpatient admission. The denial was reversed. 

This is a young male patient with a history of prematurity and constipation. He presented to the Emergency Department (ED) by his mother who had reported that the patient had fever, diarrhea, vomiting with poor oral intake and a decrease in his activity for three days. It was noted that the patient had been to the ED two days prior to this presentation with similar symptoms. He had been given Zofran and glycerin suppositories and discharged home; his vomiting had resolved. On physical exam it was noted that the patient was crying without tear production, had dry mucus membranes and sunken eyes. Laboratory work up was performed that revealed a low glucose at 56 and low carbon dioxide 14; there was concern for dehydration. The patient was admitted to the hospital and was treated with intravenous (IV) fluids, Tylenol, famotidine, and Ibuprofen. The patient was able to tolerate fluids and a diet. After a period of medical stability the patient was discharge home. 

Per Banyai, K., et al. (2018), "For treatment of dehydration caused by gastroenteritis viruses, the administration of reduced-osmolality oral-rehydration solutions (5060 mmol/L sodium) is the first line of therapy.  Profuse vomiting, worsening dehydration with altered consciousness, or severe acidosis, hypovolaemic shock, abdominal distension, and ileus are indications for intravenous rehydration".

Per Hartman S1. et al. (2019), "Acute gastroenteritis is defined as a diarrheal disease of rapid onset, with or without nausea, vomiting, fever, or abdominal pain.  In the United States, acute gastroenteritis accounts for 1.5 million office visits, 200,000 hospitalizations, and 300 deaths in children each year.  Evaluation of a child with acute gastroenteritis should include a recent history of fluid intake and output... Hospitalization and intravenous fluids are recommended for children who do not respond to oral rehydration therapy plus an antiemetic and patients with severe dehydration (i.e., signs of shock or more than 10% dehydration).  Hand washing, breastfeeding, and rotavirus vaccination reduce the incidence of acute gastroenteritis in young children."

Per Vega, R. M. and Avva, U. (2019), "Dehydration is a major cause of morbidity and mortality in infants and young children worldwide. Each year, approximately 760,000 children of diarrheal disease worldwide.  Most cases of dehydration in children are the consequence of acute gastroenteritis... Metabolic acidosis is seen in infants and children with dehydration, the pathophysiology of which is multi-factorial. 1. Excess bicarbonate loss in the diarrhea stool or in the Urine is certain types of renal tubular acidosis...Priorities in the management of dehydration include early recognition of symptoms, identifying the degree of dehydration, stabilization, and rehydration strategies."			

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient.

The carrier's denial of coverage for the hospital admission from is reversed.  The medical necessity is substantiated.