Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Vomiting and hypertension.
Treatment:  Inpatient Hospital Admission.

The insurer denied Inpatient Hospital Admission.  The denial is upheld.

The patient is an adult female. As per the emergency department (ED) note, this is a patient with history of diabetes mellitus (DM), cerebral vascular accident (CVA) with no residual deficit, hypertension (HTN), hyperlipidemia (HL), end stage renal disease (ESRD) on hemodialysis (HD) via right temporary hemodialysis catheter (THDC) on Mondays, Wednesdays, and Fridays (MWF), status post outpatient procedure on day before presentation to ED for left arteriovenous formation (AVF) creation. The patient had an episode of vomiting during the procedure, an episode vomiting at home in the evening before admission and was evaluated in the emergency department same evening. There was no vomiting while in emergency room. Labs and electrocardiogram were with no new changes. The patient was given dose of Amlodipine for elevated blood pressure, as she did not take her medications that day due to the procedure. The patient tolerated oral intake and was discharged home in the morning. The patient then returned via Emergency Medical Services (EMS), with her son, with recurrent vomiting after eating a small meal at home. The patient denied any abdominal pain, chest pain or shortness of breath; she did not have a fever or diarrhea. This patient was admitted for control of vomiting and hypertension. The issue under review is the inpatient hospitalization.

The proposed treatment was not medically necessary.

As per the Milliman Care Guidelines (MCG) National Guidelines: The main indications for admission secondary to vomiting include diabetic ketoacidosis, hemodynamic instability, and sepsis. At the time of admission, the patient did not meet these criteria being hypertensive. However, on the day of presentation, this patient met the criteria for observation care secondary to vomiting including:  1) Vomiting that persists despite emergency department care, 2) Electrolyte imbalance unable to be corrected in emergency department, 3) Pain (e.g., abdominal) with insufficient response to emergency department care, or 4) Ability to maintain oral hydration (e.g., intravenous fluid support needed) unclear.

This is consistent with the latest Letter of Appeal, which states upon presentation to the emergency department, the patient was hypertensive with elevated blood pressure of 182/82. She was noted with persistent vomiting. The Internal Medicine physician documented, ''she may have vomiting secondary to the anesthesia she received or may have ac gastritis...admitted for hydration and treatment of her symptoms.'' The plan of care included chest x-ray, Nephrology consult, serial lab evaluations and supportive care. On day #2, the patient was noted with persistent hypertension with elevated blood pressure of 203/82. She required ongoing hospitalization for continue medical management and supportive care. The management of persistent vomiting and hypertension could have been safely, effectively, and efficiently managed as observation care not requiring a full acute inpatient admission.