Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epigastric pain with vomiting.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with history of gastroesophageal reflux disease (GERD), depression, asthma, lung cancer status post lung resection, and history of bladder cancer.  The patient presented to the hospital with multiple days of abdominal pain, nausea and vomiting, and inability to tolerate anything by mouth (PO). She was seen earlier at her primary medical doctor (PMD) office and was found to be hypotensive and was referred to the hospital.  

On presentation at the emergency department (ED), the patient was hemodynamically stable and afebrile. On physical examination, she had right upper quadrant tenderness. The ultrasound (US) and computed tomography (CT) scan of the abdomen were normal with no evidence of acute cholecystitis. The patient was given three liters of fluid, and was started on intravenous (IV) Protonix, intravenous Pepcid, Reglan, and intravenous ceftriaxone. She developed an allergic reaction to ceftriaxone, and was given intravenous Benadryl and Solumendrol. Her complete blood count (CBC) revealed normal hemoglobin/hematocrit (HB/HCT) and mild leukocytosis. Her blood urea nitrogen (BUN) was 31 and potassium was 3.2. The patient was given intravenous potassium supplements to correct hypokalemia. She was made nothing by mouth (NPO) and gastroenterology (GI) consult was done and esophagogastroduodenoscopy (EGD) was recommended. The esophagogastroduodenoscopy revealed grade II esophagitis, large hiatal hernia and mild gastritis. After the endoscopy, the patient was started on diet which she tolerated very well with no recurrence of abdominal pain, nausea or vomiting. She was discharged home on Protonix 40 milligrams (mg) by mouth (PO), twice daily (BID), and advised to follow up with the gastroenterologist (GI) on an outpatient basis.

No, the proposed acute level inpatient care for the management of this patient's condition was not medically necessary.

The patient presented with several day history of abdominal pain, nausea and vomiting. She denied any history of hematemesis, melena, or hematochezia.  On admission, she was hemodynamically stable and afebrile. She was mildly dehydrated and hypokalemic and was given three liters of intravenous fluids and potassium supplement. She was started on intravenous Protonix and Pepcid and Reglan. She was made nothing by mouth and gastroenterology (GI) was consulted for further evaluation and management of her symptoms. The esophagogastroduodenoscopy revealed large hiatal hernia, grade II esophagitis and mild gastritis. . After the procedure, she was started on diet which she tolerated well.

During her hospital stay, the patient remained hemodynamically stable and her hemoglobin/hematocrit remained stable. She did not have any evidence of gastrointestinal bleed or infection or bowel obstruction that would have required any surgical intervention. She was discharged home after the esophagogastroduodenoscopy and was prescribed Protonix 40 milligrams by mouth twice daily and advised to follow up with gastroenterology. Given this clinical scenario, the patient could have been safely and appropriately managed under a lower level of care.

Esophagogastroduodenoscopy revealed large hiatal hernia, grade II esophagitis and mild gastritis. . After the procedure, the patient was started on diet which she tolerated well. During her hospital stay, she remained hemodynamically stable and her hemoglobin/hematocrit remained stable. She did not have any evidence of gastrointestinal bleed or infection or bowel obstruction that would have required any surgical intervention. She was discharged home after the esophagogastroduodenoscopy and was prescribed Protonix 40 millimgrams by mouth twice daily and advised to follow up with  gastroenterology. Given this clinical scenario, the patient could have been safely and appropriately managed under a lower level of care.