Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes Gastroparesis. 
Treatment: Inpatient Hospital Stay. 

The insurer denied inpatient hospital stay.  The denial is upheld. 

The patient is a female with a past medical history significant for type I diabetes mellitus, diabetes gastroparesis, recurrent admissions for diabetic ketoacidosis, hypertension, anemia, and chronic marijuana use, who presented to the hospital with complaints of abdominal pain, nausea, and vomiting for one day. 

The review of systems was obtained by the admitting physician. It was negative for everything except for the symptoms listed above. 

Vital signs showed temperature 36.7, respiratory rate 16, blood pressure 129/78.
The patient was in no acute distress. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. Lungs were clear to auscultation bilaterally. There was tenderness to palpation in the epigastric area with no guarding. Normal bowel sounds. 

Laboratory evaluation revealed that sodium was 135, potassium 6.0, chloride 100, bicarbonate 20, blood urea nitrogen (BUN) 13, creatinine 0.97, glucose 364. Aspartate aminotransferase (AST) was 43, alanine aminotransferase (ALT) 18, alkaline phosphatase 89. 

Computed tomography (CT) scan of the abdomen and pelvis demonstrated no acute bowel abnormalities, persistent hepatomegaly, mildly enlarged left groin lymph node.
Subsequently, the patient underwent a CT angiogram of the abdomen and pelvis with intravenous contrast that showed no evidence of mesenteric ischemia or pancreatitis. There was mild edema in the ascending colon/hepatic flexure with pericolonic stranding.
The patient was admitted to the hospital with a diagnosis of abdominal pain, nausea, vomiting due to diabetes gastroparesis. She was started on intravenous metoclopramide. The admitting physician stated that the patient should not have intravenous pain medications. 

Other admitting diagnoses included hypoglycemia, hypertension, microscopic anemia.
During the hospital stay, the patient's clinical condition improved. According to the discharge summary, the patient tolerated her diet. Her electrolytes and blood sugars normalized. Therefore, the patient was discharged from the hospital. 

The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is upheld in whole. 

The hospital stay was not medically necessary for this patient at the acute inpatient level of care. 

The abdominal pain nausea and vomiting were not associated with hemodynamic instability or peritoneal signs on the physical exam. The patient did not require treatment with intravenous pain medications, which are actually contraindicated in the setting of gastroparesis. 

There was no evidence that the abdominal pain was the result of serious medical conditions such as aortic dissection, bowel perforation, bowel ischemia, visceral organ torsion, intestinal obstruction. This was confirmed by the CT scans performed in the hospital. 

There was no mention that the abdominal pain was associated with bacteremia or toxic megacolon. The evaluation of the abdominal pain did not require the patient not to eat or drink for an extended period of time. 

Therefore, there is no reason why the severity of the patient's condition or the complexity of the services provided rose to the acute inpatient level of care. 

The abdominal pain was most likely related to previously diagnosed diabetes gastroparesis and required supportive care. The patient's condition improved within a relatively short period of time. 

Considering the clinical circumstances, the patient could have been treated at a lower level of care status.