Diagnosis: Digestive System/ Gastrointestinal (Gastroenteritis resulting in dehydration)
Treatment: Inpatient Hospital

Summary: This patient without a significant past medical history presented to the Emergency Department (ED) by ambulance @ 15:03 with a history of non-bloody, non-bilious vomiting for two days, (7 episodes total), decreased appetite and lethargy. There was no reported weight loss, fevers, diarrhea, sick contacts or difficulty breathing. He was given D10 25ml and three 100cc normal saline boluses followed by D5 normal saline @ 30cc/hour. In addition, he received a single dose of ceftriaxone. He was evaluated by Pediatric Surgery that noted no need for surgery at that time. The decision to admit him occurred @ 19:54. Serial lactate levels showed a drop to 7.2 by admission. He was noted to be more alert and active and was breastfeeding successfully in the ED. After admission, his intravenous (IV) fluids were changed to D5 1/2 normal saline @ 21cc/hour. He continued to tolerate feeds and IV fluids were stopped at 07:57 the following day. He did not vomit after admission and his heart rate varied from 132-142. No additional antibiotics were administered. He was discharged home @ 12:27 for outpatient follow-up.

The insurer has denied coverage for the acute inpatient hospital admission as not medically necessary. The denial was reversed.

This patient appears to have viral gastroenteritis with self-limited vomiting for two days resulting in significant dehydration and poor tissue perfusion that responded to aggressive intravenous repletion. His physical exam and laboratories despite relatively normal vitals were extremely concerning. He certainly had laboratory abnormalities at presentation that persisted to the time of admission to the ward showing persistent lactic acidosis to merit the inpatient acute care setting. Although he did not vomit further in the ED, a period of monitoring was required. Clearly this patient was assessed as moderately dehydrated on presentation that improved by the time of admission to his ward bed. He was adequately resuscitated in the ED to improve his clinical appearance prior to the decision to admit and continued to receive IV fluids with the ability to tolerate fluids to some extent. His care was appropriately delivered given the severity of his initial presentation with volume repletion in the ED followed by continuous hydration in a monitored setting with reassessment for improvement in his lactic acidosis. Although the patient did not vomit further, there was no expectation that he would maintain his hydration without IV supplementation. After a brief period of observation and monitoring, this patient was safely discharged with outpatient follow-up. The medical necessity is substantiated.