Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of a cholecystectomy. She presented to the emergency department with two days of abdominal pain, nausea, vomiting, and diarrhea with 10 bowel movements per day. She had recently been treated with Augmentin for a sinus infection, as well as Tylenol and Motrin, until two days prior. The vital signs were notable for tachycardia with a pulse rate of 109/minute. The physical examination was notable for a soft, nondistended abdomen with epigastric tenderness and normal bowel sounds. Lab results showed an elevated white blood cell count of 11.9 thousand per microliter (K/uL), low sodium of 134 milliequivalents per liter (mEq/L), low potassium of 3.3 mEq/L, elevated blood urea nitrogen of 21 milligrams per deciliter (mg/dL), low calcium of 8.0 mg/dL, low albumin of 3.0 mg/dL, elevated aspartate aminotransferase of 141 units per liter (U/L), elevated alanine aminotransferase of 195 U/L, and elevated alkaline phosphatase of 179 U/L. Clostridioides difficile toxin was negative. An electrocardiogram showed sinus tachycardia and T wave abnormality, consider inferior ischemia. A computed tomography scan of the abdomen and pelvis showed findings consistent with diarrhea, no evidence of colitis, and no acute pathology. She was made nil per os (NPO).
She felt improved but still had cramping abdominal pain and watery non-bloody diarrhea. Lab results showed normalized white blood cell count, low hemoglobin of 11.3 g/dL(Grams per decilitre) and hematocrit of 33.4%, normalized blood urea nitrogen, low potassium of 3.2 mEq/L, low calcium of 7.5 mg/dL, elevated aspartate aminotransferase of 136 U/L, elevated alanine aminotransferase of 157 U/L, and normalized alkaline phosphatase. An ultrasound of the gallbladder showed a 1.7 centimeter (cm) solid-appearing mass lesion in the right lobe of the liver not clearly identified on prior imaging. A gastroenterology consultation concluded that she had acute gastroenteritis, possibly viral, epigastric pain secondary to possible gastritis or nonulcer dyspepsia, and elevated transaminases due to viral or biliary pathology; the recommendation was clear liquids, Carafate, a proton pump inhibitor, and following the transaminases.
She had worsened epigastric pain, nausea, and vomiting, with continued watery diarrhea approximately every 20 minutes. Lab results showed a hemoglobin of 10.9 g/dL and hematocrit of 34.4%, elevated aspartate aminotransferase of 11 U/L, and elevated alanine aminotransferase of 132 U/L. Ova and parasite testing was negative.
The nausea and vomiting had resolved, but she still had burning epigastric pain and diarrhea. Lab results showed a low hemoglobin of 11.3 g/dL and hematocrit of 35.3%, low calcium of 7.2 mg/dL, elevated aspartate aminotransferase of 57 U/L, and elevated alanine aminotransferase of 155 U/L. An esophagogastroduodenoscopy showed antral gastritis. A colonoscopy showed a normal terminal ileum, left-sided diverticulosis, sigmoid colon polyp, and internal hemorrhoids; the recommendation was to await pathology, low-fiber diet, dicyclomine, Imodium or Lomotil as needed, and discharged home from a gastrointestinal perspective.
She tolerated solid food without nausea or vomiting, but had persistent epigastric pain and diarrhea. Lab results showed an elevated white blood cell count of 11.2 K/uL, low hemoglobin of 11.5 g/dL and hematocrit of 35.1%, low sodium of 133 mEq/L, low calcium of 6.9 mg/dL, elevated aspartate aminotransferase of 101 U/L, and elevated alanine aminotransferase of 110 U/L. She reported resolution of diarrhea. Lab results showed a low hemoglobin of 10.7 g/dL and hematocrit of 32.8%, low sodium of 133 mEq/L, elevated alanine aminotransferase of 69 U/L, and elevated aspartate aminotransferase of 68 U/L. She was discharged, with a plan for primary care and gastroenterology follow-up.
At issue is the medical necessity for an inpatient level of care.
The inpatient stay was not medically necessary.
The patient had symptoms (nausea, vomiting, diarrhea, and abdominal pain) consistent with an infection such as gastroenteritis, and imaging showing a lack of complications such as colitis, bowel perforation, and bowel obstruction. The standard of care for the evaluation of gastroenteritis was appropriately performed, including intravenous fluids and gradual advancement of diet. No other cause for the inpatient level of care, such as inflammatory bowel disease flare, peritonitis, toxic megacolon, sepsis, abscess, fistula, or other complication was documented either. The esophagogastroduodenoscopy and colonoscopy did not show any findings such as gastrointestinal bleeding or colitis which might warrant the inpatient level of care, and discharge was recommended after the procedures. Although the liver enzymes were elevated, there was no evidence of biliary obstruction, biliary or pancreatic mass, bile leak, ascending cholangitis, hepatic abscess, or other complications which would require the inpatient level of care. Based on the available information, the care which was undertaken, including observation, monitoring, labs, and empiric antibiotics could have been performed at a lower level of care than inpatient level of care. Per the Milliman Care Guidelines for Gastroenteritis, inpatient admission criteria are not met. Based on the available information, the care, which was undertaken, including observation, monitoring, labs, and empiric antibiotics could have been performed at a lower level of care than inpatient.