Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperemesis Gravidarum

Treatment: Inpatient stay

The insurer denied the inpatient stay.

The denial was upheld.  

This is a female patient at 6 weeks gestation with no significant past medical history. The patient presented to the Emergency Room (ER) with complaints of vomiting and diarrhea. The patient's vital signs in the ER were: temperature 97.9, heart rate 79, respiratory rate 18, blood pressure 107/68, and oxygen saturation of 100% in room air. The patient's bloodwork showed: white blood cell (WBC) count of 10.2, hematocrit of 37.2, blood urea nitrogen (BUN)/Creatinine of 4/0.6, and electrolyte within normal limits. The patient was given (intravenous) IV fluids, Zofran, and Reglan on an outpatient basis with no improvement.  An ultrasound revealed an intrauterine gestational sac.  The patient continued to report symptoms of nausea and vomiting despite treatment with IV fluids and anti-emetics.  The patient was admitted to the hospital with hyperemesis gravidarum.  The patient's medical management included continued IV fluids, IV Zofran every 4 hours, and oral famotidine twice a day, and advance to a soft diet as tolerated; the patient's symptoms improved. The patient was discharged home with instructions to follow up with the obstetrician on an outpatient basis.

As per the American College of Obstetricians and Gynecologists (ACOG), there are no controlled trials comparing hospitalization with outpatient management of hyperemesis gravidarum.  When a woman cannot tolerate liquids without vomiting and has not responded to outpatient management, hospitalization for evaluation and treatment is recommended.  After the patient has been hospitalized on one occasion and a workup for other causes of severe vomiting has been undertaken, intravenous hydration, nutritional support, and modification of antiemetic therapy often can be accomplished at home. Nevertheless, the option of hospitalization for observation and further assessment should be preserved for patients who experience a change in vital signs or a change in affect or who continue to lose weight.

According to UpToDate, women who are unable to maintain adequate hydration, normal electrolyte levels, and acid-base balance with the initial interventions described above should be admitted to the hospital for IV fluids and medications.  Women who have severe vomiting, weight loss, ketonuria, dry mucous membranes, poor skin turgor, dehydration, hypotension, alkalosis from hydrochloric acid loss, hypokalemia, or nutritional deficiencies are admitted to the hospital.  In women with persistent vomiting after hospitalization, it is important to exclude underlying diseases that can cause hyperemesis.

As per literature review, the clinical indication for inpatient admission is for severe case of hyperemesis gravidarum supported by abnormal lab findings. In this case, this patient did not have severe hyperemesis. The patient was hemodynamically stable with normal lab findings. On exam, the patient was noted to be well-appearing, well-nourished, and in no apparent distress. There was no indication of dry mucous membranes, poor skin turgor or documentation of weight loss. 

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the acute inpatient stay is upheld.  The medical necessity is not substantiated.