Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a female teen with history of ovarian cyst that was referred to the emergency department (ED) by her primary care provider for evaluation of abdominal pain. She reported same day history of abdominal pain, nausea, and diarrhea. She began to have periumbilical pain in the morning that over time migrated to the right lower quadrant, rated eight out of ten (8/10) at the worst. She had no fever or vomiting. 

The patient's vital signs included temperature 37, heart rate 114, and respiratory rate 20. Examination was significant for no apparent distress (NAD), right lower quadrant tenderness with mild rebound tenderness, and non-focal neurologic exam. She was treated with three intravenous fluid boluses (given for blood pressure 87/33 which improved to 101/58), Tylenol for pain, and ibuprofen for fever to 101.1. Appendix ultrasound was unremarkable. Pelvic ultrasound was unremarkable. Urinalysis was significant for moderate leukocyte esterase and 13 white blood cells (WBCs), and blood and urine cultures were sent. Laboratory evaluation was unremarkable. The patient was given a dose of ceftriaxone and admitted for observation. Differential diagnoses included pyelonephritis, gastroenteritis, and ovarian torsion (unlikely given negative pelvic ultrasound). Admission orders included antipyretics as needed, follow-up cultures, cardiorespiratory monitoring, clear liquid diet, stool studies, and maintenance intravenous fluids. Her diarrhea initially worsened and gastrointestinal (GI) polymerase chain reaction (PCR) returned positive for Norovirus. Her symptoms subsequently improved, with resolution of abdominal pain and nausea. She was able to tolerate her diet and maintained good urine output. She had no further episodes of hypotension. She remained on ceftriaxone pending culture results. Blood culture was preliminary negative. She was deemed stable for discharge home to follow-up the urine culture with her primary care practitioner. 

No, the acute inpatient admission was not medically necessary for this patient. 

Acute gastroenteritis is a major problem worldwide, representing one of the leading causes of morbidity and mortality in children. There are an estimated 2.5 million deaths each year attributable to gastroenteritis in children under the age of five years. Most cases are caused by viruses, are self-limited, and require supportive treatment. According to the World Health Organization, oral rehydration therapy is the treatment of choice, particularly where diarrhea is the prominent feature and dehydration is mild to moderate. Intravenous rehydration is indicated when oral rehydration fails or when output is excessive. Output (vomiting, diarrhea) limits the success of oral rehydration, prompting use of anti-emetic medications. According to current guidelines for evaluation and management of acute diarrheal illness, people with fevers or bloody diarrhea, as well as severe cramping or signs of sepsis, should undergo diagnostic studies to determine if antimicrobial agents are appropriate. Additional testing such as blood cultures may also be indicated. 

According to a national surveillance system maintained by the Centers for Disease Control (CDC), the leading pathogens for acute diarrheal illness included Norovirus and Salmonella enterica, with Norovirus the more likely cause of illness and Salmonella being the more likely cause of hospitalization. Prior to vaccination, rotavirus was the most common pathogen in young children. The most common bacterial pathogens include Salmonella enterica, Campylobacter, Shigella, Yersinia, and Escherichia (E) coli. Avoiding dehydration or treating it once it occurs is the mainstay of management. Increased resistance to antimicrobials and risk of worsening illness may result from use of antimicrobial and antimotility agents respectively. 

This female teen presented with acute onset diarrhea and abdominal pain, initially concerning for possible appendicitis or ovarian torsion. Positive urinalysis was concerning for urinary tract infection. Stool studies revealed Norovirus infection. In the emergency department, the patient was hypotensive (80s/30s) but responsive to three normal saline boluses with no recurrence of hypotension. She had no signs of shock or hemodynamic instability. While it was appropriate to monitor her in the hospital for ability to tolerate adequate fluids by mouth, she did not require acute inpatient admission and could have been safely managed at a lower level of care like observation.