Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal
Treatment: Inpatient Hospital
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department with concerns for nausea, diarrhea, and fevers. Pertinent history included gastroesophageal reflux disease. Initial vital signs revealed a temperature of 99.5 degrees Fahrenheit [F] (maximum temperature [Tmax] 101 degrees Fahrenheit [F]), heart rate (HR) 125, blood pressure (BP) 131/88, respiratory rate (RR) 20, and peripheral capillary oxygen saturation (SpO2) 99% on room air. Initial examination documented the patient as alert, oriented, and without peritoneal signs. Initial laboratory testing revealed a white blood cell count (WBC) 15.3, hemoglobin (Hgb) 13.0, blood urea nitrogen (BUN) 13, creatinine (Cr) 0.6, glucose (Glu) 129, sodium (Na) 137, potassium (K) 4.6, carbon dioxide (CO2) 23. A computed tomography (CT) scan of the abdomen/pelvis revealed findings consistent with a duodenitis. The patient was admitted to the hospital with an impression of acute enteritis. The treatment plan included intravenous fluids, empiric antibiotics, and supportive care. The stool was positive for Norovirus. Her symptoms significantly improved, white blood cell count (WBC) normalized, and she was deemed medically stable for discharge.

Based on the clinical documentation provided, evidence-based literature and standards of care, acute inpatient level of care was not medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care with transition to outpatient services.
The patient presented with signs and symptoms consistent with a gastroenteritis. Initial evaluation revealed a fever, tachycardia, leukocytosis, radiographic findings consistent with duodenitis, and a stool polymerase chain reaction (PCR) positive for Norovirus. Treatment included intravenous fluids and supportive care. Following a one-night stay, the patient experienced significant clinical improvement and was deemed medically stable for discharge with a prescription for probiotics.
Glass et al. note the treatment for Norovirus gastroenteritis, like that for other diarrheal illnesses, is oral rehydration with fluids and electrolytes, if the patient is alert and able to drink, or with intravenous fluids, if vomiting and dehydration are severe. Antimotility and antisecretory agents can be useful in adults to decrease diarrhea in situations in which a person's performance is critical.[1]
In this particular situation, the patient was diagnosed with a gastroenteritis and the aforementioned treatment was provided. In regards to level of care required, clinical indications for admission to inpatient care were not met. The patient did not have a suspected severe infection (eg, bloody diarrhea, immunosuppressed state), severe abdominal pain, peritoneal signs, toxic megacolon, hemodynamic instability, severe or persistent vomiting, severe or persistent dehydration, electrolyte or metabolic abnormality that is severe or persists despite observation care (eg, acidosis, alkalosis, hyponatremia, hypernatremia), hemolytic uremic syndrome, or an inability to maintain oral hydration that persists at an observation level of care.[2]