Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea, vomiting, diarrhea, irregular heart rate.
Treatment: Inpatient admission.
The insurer denied the inpatient admission. 
The denial is upheld. 

No, the proposed inpatient admission is not "medically necessary".

The patient is a female who presents to the emergency room with complaints of nausea, vomiting and diarrhea.  She reports discomfort in the mid and left lower abdominal area. Past medical history was notable for hyperlipidemia, hypertension, asthma, borderline diabetes and obesity.

Vitals: Blood pressure 109/75, heart rate 71 bpm, respiratory rate 18, oxygen saturation 98% on room air, and temperature 96.1F. 

Physical examination noted "weak appearing", tachycardia, and mild epigastric tenderness. 
Laboratory studies: Sodium 138, potassium 4.8, chloride 102, carbon dioxide 21, BUN 13, creatinine 0.66, serum glucose 142, calcium 9.6, white cell count 14.11, hemoglobin 15.6, and Platelet 251. 

Echocardiogram showed atrial fibrillation with rapid ventricular response at 113 bpm.

CT abdomen and pelvis showed mild small bowel enteritis.

Transthoracic echocardiogram was notable for grade 1 diastolic dysfunction.

The patient was admitted to inpatient telemetry with diagnosis of new onset atrial fibrillation, gastroenteritis, non-intractable vomiting with nausea, hypotension, unspecified type and dehydration. 

Cardiology consult indicated that the patient converted to sinus rhythm spontaneously.  It was also noted that on presentation, the patient was hemodynamically stable.  There was no documentation of palpitations, shortness of breath, chest pain, orthopnea, dizziness or syncope.  

The patient received one dose of Lovenox in the emergency department.  Cardiology attending deferred anticoagulation due to spontaneous conversion to some sinus rhythm in less than 24 hrs.  It was noted that there was no evidence of acute coronary syndrome; stress test showed no ischemia with EF of 69%.  Echocardiogram showed normal left ventricular function without significant valve abnormalities.  Recommendation by cardiology was switching lisinopril to Cardizem. 

Hospitalist attending note indicated that the patient was tolerating clear liquid diet. Further hospital investigation (GI PCR) showed positive norovirus and she was treated conservatively with bowel rest and fluids.

The patient was deemed stable, and was discharged. 

For most patients with acute viral gastroenteritis, management can be done in the outpatient setting. Potential indications for hospitalization may include volume depletion/dehydration, intractable vomiting, abnormal electrolytes or renal function.   The patient was hemodynamically stable on admission; there was no evidence of intractable vomiting, or vomiting that is severe or persistent, significant volume depletion/dehydration, acute renal failure, nor electrolyte imbalance. CT abdomen and pelvis showed mild small bowel enteritis, without complete ileus/signs of intestinal obstruction or peritonitis.  She was treated conservatively for acute viral gastroenteritis. 

In patients with newly diagnosed atrial fibrillation, most cases can often be managed in an outpatient setting.  Indication for inpatient management may include hemodynamic instability, myocardial infarction/ischemia or heart failure. Although hospital records indicate that the patient was admitted with new onset atrial fibrillation. Please note that evaluation by the cardiology service indicates that atrial fibrillation, converted to normal sinus rhythm spontaneously.  There was no indication that the patient remained in persistent cardiac arrhythmia that will require inpatient admission.  She remained hemodynamically stable throughout the hospitalization.

In view of the foregoing, inpatient admission was not medically necessary because the care rendered could have been performed at a lower level of care without adversely affecting the patient's health.