Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea, Vomiting, Diarrhea 
Treatment: Inpatient Hospital Stay 

The insurer denied the inpatient hospital stay. 
The determination is upheld. 

The patient has a past medical history significant for hypertension, heart failure with reduced ejection fraction, non-ischemic cardiomyopathy, and alcohol abuse who presented to the hospital with complaints of diarrhea, nausea, vomiting, and abdominal pain. 

It was reported that the patient has previously been admitted for similar symptoms. However, after the discharge, his diarrhea became worse. He reported an average of 7 bowel movements a day, including during the nighttime. The patient stated that he consumed alcohol heavily, and his symptoms were exacerbated by eating meals and became better if he did not drink alcohol. Reportedly, he had a colonoscopy, which did not show any obvious findings. At the time, he also had a negative esophagogastroduodenoscopy (EGD) study. 

The review of systems was negative for a fever, chills, skin rashes, joint pain, bright red blood per rectum, melena, dysphagia. The patient reported significant weight loss, but the admitting physician was unable to verify that. 

Vital signs at the time of admission were a temperature of 97.3 degrees Fahrenheit, blood pressure 179/110, pulse rate 80 beats per minute (bpm), respiratory rate 18 breaths/minute, and oxygen saturation 100% on room air. 

The patient was in no acute distress, he looked thin. He had moist mucous membranes. His cardiac exam was unremarkable and the lungs were clear to auscultation. The abdomen was soft, non-distended, there was mild lower abdominal tenderness to palpation. The rest of the physical exam was unremarkable. 

Laboratory evaluation revealed that the white blood cell count was 4.0, hemoglobin 11.9, hematocrit 32.6, and platelets 325. The sodium was 146, potassium 3.4, chloride 101, bicarbonate 35, blood urea nitrogen (BUN) 9, creatinine 1.0, and glucose 94. Liver function tests were unremarkable. The lipase was normal. 

A computed tomography (CT) scan of the abdomen and pelvis revealed mural thickening of the entire colon. The differential diagnosis included infectious versus inflammatory versus less likely ischemic etiologies. 

The patient was admitted to the hospital with a diagnosis of chronic diarrhea, nausea, vomiting, episodes of hiccups. In the hospital, the patient underwent a workup that included a gastroenteritis panel, stool for Clostridium (C) difficile, ova, and parasites. All of these studies were negative. The additional evaluation included a human immunodeficiency virus (HIV) test, which was also negative. A C-reactive protein (CRP) was low. 

In the hospital, the patient was seen by a gastroenterology (GI) specialist who did not recommend a colonoscopy, since inflammatory bowel disease and microscopic colitis were ruled out during his previous colonoscopy last year. Nausea and vomiting mentioned at the time of admission were attributed to alcoholism. While in the hospital, the patient's symptoms including nausea, vomiting, abdominal pain, diarrhea, and hiccups resolved. Since the patient's vitamin D level was low, he was started on vitamin D supplements. Because his blood pressure was on the high side, the dose of Lisinopril was increased. During the hospital stay, the patient was ordered treatment with Librium for alcohol withdrawal symptoms. Since the patient's clinical condition continued to improve, he was transitioned to outpatient care. 

At issue is the medical necessity of an inpatient stay. 

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

This patient presented to the hospital with complaints of nausea, vomiting, diarrhea, decreased appetite, and hiccups. These symptoms were chronic. Despite the presence of the symptoms, this patient was afebrile and hemodynamically stable. The results of the physical exam were not alarming. There was no evidence that the patient had an acute abdomen. The laboratory studies did not demonstrate clinically significant electrolyte abnormalities, signs of severe or profound dehydration, or kidney failure. The CT scan of the abdomen and pelvis looked abnormal and required further attention. Taking into consideration all of this information, it was reasonable to work up his gastrointestinal symptoms and to ensure improving his oral intake. 

However, the review of the medical records demonstrated that neither the severity of the patient's condition nor the complexity of the services provided justified admission at the acute inpatient level of care. The workup could have been performed at a lower level of care. 

There is no strong evidence that the patient had significant alcohol withdrawal symptoms necessitating admission at the acute inpatient level of care. It was noted in many notes including the nursing notes, that the patient had no alcohol withdrawal symptoms. 

Overall, he remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.