Diagnosis: Autism Spectrum Disorder.
Treatment: Inpatient Hospital.
The insurer denied inpatient stay for medical necessity.
The denial was overturned.

The patient is a male with severe autism who is non-verbal. He presented to the emergency room (ER) with refusal of by mouth (PO) for 6 days. Per his father he stopped eating suddenly without apparent inciting factors. Since then, he had only taken water PO, no solids, or additional liquids. He had associated weight loss on day of presentation (10.4% loss). Per his father, the patient has had similar episodes of PO refusal in the past. He was hospitalized. At baseline he is a picky eater with a restricted diet. He had some increased fatigue, taking 1-2 naps per day (patient does not nap at baseline). He was not complaining of abdominal pain, throat pain, or mouth pain. Per his father, the patient is usually able to communicate when he has pain or physical complaints. He had no vomiting, diarrhea, or upper respiratory infection (URI) symptoms. He had a tooth extraction 10 days ago and had not been complaining of pain. He had no recent illnesses, and no known sick or coronavirus positive (COVID+) contacts.
The physical exam in the ER was documented as lips dry, and tacky mucous membranes. His labs were notable for a potassium (K) at 5.1, Bicarbonate was 16, Creatinine was 0.62, and complete blood count (CBC) was not concerning. He was admitted to the pediatric floor with a diagnosis of PO refusal, weight loss and dehydration. There was concern for failure to thrive in the ER due to his 5 pounds (lbs.) weight loss in the past month.
The nutritionist cautioned to monitor for refeeding syndrome if he continued with food refusal for greater than or equal to (>/=) 7 days. The patient continued to have decreased PO intake; however, he had improved urine output on fluids. With improving lab results and physical exam he was deemed stable for discharge with follow up and with strict return precautions.
At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of inpatient stay was medically necessary for this patient.
This patient, presented with physical signs of dehydration as documented by the ER physician. He was found to have low carbon dioxide (CO2), an indicator for metabolic acidosis, as well as PO refusal. The child also has a diagnosis of autism and chronic issues with feeding, intermittently failing to thrive and anorexic behaviors. Multidisciplinary care which would address his nutritional concerns, feeding concerns, developmental barriers, as well as the presenting diagnosis would be necessary. Of concern are complications that may arise such as refeeding syndrome if he continued to refuse PO and eventually required nasogastric (NG) feedings. Given his chronic state of poor feeding, intermittent failure to thrive and the acute PO refusal and dehydration, the inpatient level of care was necessary to care for this patient.
Therefore, the inpatient stay was medically necessary.