Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

This patient is an infant with a past medical history of respiratory syncytial virus (RSV) and acute viral gastroenteritis with recent admission that re-presented by ambulance to the Emergency Department for recurrent non-bilious, non-bloody vomiting 8-9 times, tactile fever, decreased activity, decreased oral intake and decreased urine output since discharge from the same institution 6-7 hours prior to arrival. The patient's vitals on arrival were notable for heart rate 137 (was 113 at discharge), Temperature 36.3 degrees Celsius (C), respiratory rate 36 and room air oxygen saturation of 100%. Admitting weight was 14.7 kilograms (was 15.6 last admission) and the height was 85.5 centimeters (was 91.5 last admission). Physical exam showed an alert, non-toxic infant in no apparent distress. The infant had moist mucus membranes and normal capillary refill (< (less than) 2 seconds). Admitting laboratories were notable for a sodium of 141, chloride 106, bicarbonate 18, blood urea nitrogen 12, creatinine 0.52, glucose 85, amylase 57, lipase 31 and an unremarkable hepatic profile. The team decided to admit the infant because the patient returned soon after being discharged. The infant received a 20 milliliters per kilogram normal saline bolus after arrival to the inpatient setting followed by Dextrose 5% normal saline at maintenance. In addition, the infant received oral Zofran 2.2 milligrams (mg). The patient received intravenous and oral fluids without vomiting during the admission. No repeat laboratories were performed. The infant received no antibiotics or additional anti-emetics. The weight change during the admission was 0.3 kilograms (kg) (2%). The heart rate at discharge was 119.

The reasons to admit such an individual would include signs of significant dehydration poorly responsive to intravenous hydration in the Emergency Department, significant weight loss, profound lethargy, 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. The infant did not meet any of these criteria to merit the acute inpatient setting. The treating team noted both the lack of signs of dehydration and the normal heart rate for age as evidence that the patient was not dehydrated despite returning with recurrent vomiting. Refusing to drink in the Emergency Department does not constitute oral intolerance.

The documentation of this child's appearance and vitals at presentation would indicate no dehydration. After oral Zofran and modest intravenous resuscitation, the vomiting never recurred since presentation. The laboratory abnormalities were not critical and would be expected to correct with fluid resuscitation followed by oral rehydration therapy. The weight change from one admission to the other seems to be unreliable since the infant seems to have shrunk 6 centimeters between admissions. After admission, the infant was merely observed with both modest intravenous and oral fluids, and safely discharged on oral fluids with outpatient follow-up. The infant received no acute care after admission to merit reimbursement at that level. Oral rehydration with or without solids after oral Zofran could have been administered as an outpatient in the Emergency Department with maternal reassurance. In regard to the acute inpatient admission the determination by the carrier that the admission was not medically necessary was correctly applied, objective, clinically 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 attached reviews from UpToDate summarizing the approach to acute gastroenteritis and dehydration in children.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is not substantiated.