Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dehydration, Metabolic Acidosis.

Treatment: Inpatient admission.

The insurer denied the inpatient admission.

The denial was upheld.

This is a male patient with a past medical history notable for prematurity (32 week gestation), autistic spectrum, and mild asthma. He was transferred from a medical facility to a pediatric facility for management of non-bloody, non-bilious vomiting and non-bloody diarrhea associated with decreased oral intake for several days. The patient's vital signs on arrival were: Heart Rate 123, Temperature 99.1 F, Respiratory Rate 25, Blood Pressure was 90/50 and room air oxygen saturation of 100%. His weight was 16.6 kilograms.  Physical exam showed he was awake, alert and in no apparent distress.  He had moist mucus membranes, normal capillary refill and clear lungs. Abdomen exam was soft with normal bowels sounds with no associated tenderness, guarding, organomegaly, distension, rebound, or masses. An abdominal x-ray was done that was that was unremarkable. He received intravenous (IV) fluids D5NS. He was admitted to the hospital for further treatment. There were no further episodes of documented vomiting or diarrhea after admission.  Repeat laboratories were performed; sodium 140, potassium 3.5, chloride 106, bicarbonate 22, BUN 3, creatinine 0.24, and magnesium 1.4. IV fluids continued until and he was able to tolerate a normal diet.  He was medically stable and discharged home for outpatient follow-up.  
A review 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, 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.  
"Degree of dehydration - Fluid repletion guidelines for children with gastroenteritis by the American Academy of Pediatrics, Centers for Disease Control, and the World Health Organization are based upon the degree of volume depletion.  As a result, it is important to be as accurate as possible when assessing the degree of dehydration.  Severe hypovolemia requires rapid isotonic fluid resuscitation, although oral rehydration may be sufficient for mild to moderate hypovolemia.
1)	   Mild dehydration (3 to 5 percent volume loss) - A history of fluid losses may be the sole finding, as clinical signs may be absent or minimal.  Such patients may have a reduction in urine output, but this may not be appreciated.
2)	   Moderate dehydration (6 to 9 percent volume loss) - Signs and symptoms are now apparent and can include the following: tachycardia, orthostatic falls in blood pressure, especially with orthostatic changes, decreased skin turgor, dry mucous membranes, irritability, decreased peripheral perfusion with a delay in capillary refill between two and three seconds, and deep respirations with or without an increase in respiratory rate.  There may be a history of reduction in urine output and decreased tearing and, in infants, an open fontanelle will be sunken on physical examination.
3)	   Severe dehydration (>=10 percent volume loss) - Such children typically have a near-shock presentation as manifested by hypotension, decreased peripheral perfusion with a capillary refill of greater than three seconds, cool and mottled extremities, lethargy, and deep respirations with an increase in rate.  Severe hypovolemia requires immediate aggressive isotonic fluid resuscitation to restore the ECV and prevent ischemic tissue injury"
Inpatient admission was not medically necessary. The health plan acted reasonably with sound medical judgment in the best interest of the patient.
The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.