Diagnosis: Dehydration
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a male child. He presented to the ER (emergency room) with approximately 4 days of minimal to no food intake, significant decrease in oral fluid intake with the patient only taking water and no fever noted. The patient had seen the pediatrician prior to the ER (emergency room) visit, they were diagnosed with a viral syndrome and were told no emergency services were needed.

Upon evaluation in the ER (emergency room), the patient exhibited no signs of distress, no difficulty in waking, no fussiness, no diarrhea or vomiting or abdominal pain or inconsolable crying noted nor fever. The patient was noted to be non-toxic appearing with no symptoms of distress noted, and only abnormal exam findings were dry lips. The vitals were evaluated and normal. The patient did not have a failed PO (per os - oral) challenge in the ER (emergency room) noted.

No, the Inpatient admission was not medically necessary.
Upon evaluation in the ER (emergency room), the patient exhibited no signs of distress, no difficulty in waking, no fussiness, no diarrhea or vomiting or abdominal pain or inconsolable crying noted nor fever. The patient was noted to be non-toxic appearing with no symptoms of distress noted, and only abnormal exam findings were dry lips. The vitals were evaluated and normal, but that is not telling, as vitals (especially heart rate and blood pressure) can be normal until severe symptoms of dehydration (representing a loss of [greater than] > 10% (percent) of fluid) are present. The patient did not have a failed PO (per os - oral) challenge in the ER (emergency room) noted. For mild and moderate dehydration, oral hydration is recommended by the AAP (American Academy of Pediatrics) and WHO (World Health Organization).

The patient had no documented symptoms showing distress or decompensation or an inability to take liquids by mouth. Appropriate oral rehydration solutions such as Pedialyte, were attempted in the ER (emergency room). The carbon dioxide was noted to be lower, at 14, where a level of 15 and above is preferred. But with no symptoms of difficulty maintaining fluids (no diarrhea, vomiting) and an exam lacking signs of moderate/severe dehydration, as well as no other abnormalities noted on lab assessment, the admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.