Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cyclic Vomiting Syndrome
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of gastroparesis versus cyclic vomiting syndrome, gastroesophageal reflux disease (GERD), Helicobacter (H) pylori, and hyperthyroidism who presented to the hospital with persistent nausea and vomiting x (times) 3 days (per the emergency department (ED) note; only 1 day per the admission note) along with left lower quadrant (LLQ) abdominal pain and diarrhea. She had recent visits to the ED (three times in the last week) for the same symptoms, which were thought to be secondary to marijuana use. She had been unable to tolerate a by mouth (PO) diet for 2 days. She denied taking marijuana for a year per the history and physical (H&P), but per the ED note she was taking marijuana the prior Tuesday.

On presentation, she was noted to be pregnant. In the ED she was afebrile and hemodynamically stable with a blood pressure of 143/88 millimeters of mercury (mmHg) and pulse of 86 beats per minute (BPM). A pelvic ultrasound showed a 2.4 cm ovarian cyst without signs of torsion. She was given Zofran and fluids in the ED. On re-assessment, the patient noted no improvement in her symptoms and continued to be unable to tolerate PO food and medications per the ED note. She was evaluated by an Obstetrics and Gynecology (OB/GYN) physician, who felt the symptoms were due to cyclic vomiting syndrome (CVS) rather than hyperemesis from pregnancy. The patient was admitted to the hospital for further treatment of CVS and possible gastroenteritis. She was started on a clear liquid diet and given intravenous (IV) fluids. An H. pylori stool antigen and stool cultures were ordered. She was started on IV Pepcid. Her potassium was elevated at 5.3 but this was thought to be a hemolyzed sample. During the hospitalization, she continued to experience nausea and vomiting, and she could not tolerate a PO diet. IV fluids were continued. Her potassium was mildly low at 3.1 and was replenished. Her symptoms resolved and she was tolerating a diet. She was discharged home with plans to follow up with her primary care physician (PCP) and OB/GYN after discharge.

At issue is the medical necessity of an inpatient stay.

Inpatient admission was not medically necessary for this patient. The patient could have been treated at a lower level of care. She met Milliman Care Guidelines (MCG) for a lower level of care as the stay was expected to be short-term and she required monitoring after treatment with anti-emetics and IV fluids. She had no complicating issue that would indicate that she would require an inpatient stay. She was hemodynamically stable and was not felt to be septic. Her symptoms were not thought to be related to a complication from her pregnancy. She had only mild electrolyte disturbances (mild hypokalemia and hypophosphatemia) that required simple repletion and no more frequent than daily blood work checks. She did not have dehydration that caused an acute kidney injury. She had several recent ED presentations that did not require admission. The therapeutic aim in cyclic vomiting syndrome is to prevent dehydration, renal insufficiency and electrolyte depletion. With anti-emetics, IV fluids, and basic electrolyte monitoring and repletion, this could have been done at a lower level of care.