Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal/stomach pain
Treatment: Inpatient hospital admission
The health plan denied Inpatient hospital admission.
The determination is Upheld.

The patient is a male with a medical history of diabetes mellitus type 1, gastroparesis, chronic kidney disease, and cannabinoid hyperemesis syndrome. He presented to the emergency department with left lower quadrant abdominal pain, nausea, vomiting, and chills for four days. His vital signs were notable for an elevated blood pressure of 176/109 millimeters of mercury (mmHg) and tachycardia with a pulse of 109 beats per minute (bpm). The physical examination was notable for a soft, nontender abdomen with normal bowel sounds. The labs showed an elevated white blood cell count of 12.5, a low sodium of 134, an elevated blood urea nitrogen (BUN) of 22, an elevated creatinine of 1.4, and an elevated glucose of 292. An x-ray of the abdomen showed no visceral distention or pneumoperitoneum.
He was treated with intravenous (IV) ondansetron and fluid and oral amlodipine. Gastroenterology consultation noted it was likely a gastroparesis flare; the recommendation was to optimize glucose control, repeat hemoglobin A1C, symptomatic control with Zofran as needed, famotidine, minimize narcotic use, encourage marijuana cessation, encourage mobilization, and initiate a gastroparesis diet; outpatient endoscopy was recommended, and Gastroenterology signed off.
The next day, his labs showed a low hemoglobin of 13.2, a hematocrit of 39.3 and an elevated BUN (blood urea nitrogen) of 22. The following day, he denied nausea, vomiting, and abdominal pain; he was started on amlodipine to control blood pressure. The labs showed a low hemoglobin of 12.7, a hematocrit of 35.5, a low sodium of 133, a low potassium of 3.2, an elevated BUN (blood urea nitrogen) of 24, and an elevated creatinine of 1.5. Diabetes consultation recommended modification of the insulin regimen. After three days, he had symptomatic improvement. The labs showed a low hemoglobin of 12.7, a hematocrit of 37.7, and an elevated creatinine of 1.4. He was discharged with a plan for Primary Care and Podiatry follow-up.
At issue is the medical necessity of the inpatient level of care.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of inpatient hospital admission is not medically necessary for this patient. Although the patient presented with nausea, vomiting, and abdominal pain, he did not have persistent hypotension, organ failure, or other stigmata of severe volume depletion. The presenting gastrointestinal symptoms of nausea and vomiting with abdominal pain were consistent with his known gastroparesis or other etiologies such as cannabinoid hyperemesis syndrome [1-6]. However, the patient did not have evidence of bowel obstruction, peritonitis, abscess, fistula, sepsis, gastrointestinal bleeding, or other complications warranting inpatient level of care [7,8]. All of the measures that were undertaken, including observation, monitoring, labs, Gastroenterology consultation, antiemetic therapy, and intravenous fluids with gradual advancement of diet, could have been performed in sequence after presentation and without the inpatient level of care, at an alternate level of care [1-8].