Diagnosis: Gastroenteritis, Urinary Tract Infection
Treatment: Inpatient Admission

The insurer denied the inpatient admission. The denial was reversed.

This patient is male child who presented to the Emergency Department (ER) with complaints of vomiting for three days with poor oral intake. A laboratory work up was performed revealing a white blood cell (WBC) count was 20.5, a carbon dioxide level (CO2) of 7 and severe acidosis with bicarbonate level of 7. A urinalysis was obtained which was suspicious for urinary tract infection. The patient received intravenous (IV) fluids, IV antibiotics, and IV anti-emetics. The patient was medically stabilized and discharged home.

While literature indicates that most gastroenteritis cases do not require inpatient care, patient who develop severe dehydration and require intravenous hydration require hospital care. Per Bányai, K., et al. (2018) "For treatment of dehydration caused by gastroenteritis viruses, the administration of reduced-osmolality oral-rehydration solutions (5060 mmol/L sodium) is the first line of therapy. Profuse vomiting, worsening dehydration with altered consciousness, or severe acidosis, hypovolaemic shock, abdominal distension, and ileus are indications for intravenous rehydration". Articles such as Hartman S1 et al (2019) and Vega and Avva (2019) emphasize the risk of high morbidity and mortality of dehydration in infants and young children, and that proper rehydration should be prioritized for proper care.

This patient's clinical signs and symptoms of dehydration and acidosis were particularly concerning because of this patient's inability to rehydrate orally. The patient's vomiting and poor oral intake indicated that this patient required intravenous rehydration, in order to restore this patient's urine output and prevent cardiovascular collapse in the setting of an infection. The patient was noted to have gastroenteritis, likely viral and a suspicion for urinary tract infection on his urinalysis.

The plan did not act reasonably with sound medical judgement and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital services is reversed. The medical necessity is substantiated.