Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Cellulitis; hyperemesis gravidarum; anemia

Treatment: Acute inpatient stay 

The insurer is denied coverage for acute inpatient stay. 

The denial is modified.  


The patient was then a female in her second trimester of gestation with no significant past medical history who presented to the Emergency Department (ED) with complaints of worsening nausea and vomiting for the last two days. The patient was on a home intravenous (IV) Reglan pump that was administered by a nurse. On exam, there was purulent discharge in the patient's left arm where her IV access was obtained. The patient's temperature was elevated at 101.5 F. The patient was admitted with a diagnosis of cellulitis and hyperemesis gravidarum and anemia. 

Progress note showed that the patient was afebrile, feeling better with clinical improvement of her cellulitis. Though the patient was not vomiting, the patient was unable to tolerate oral intake due to nausea. The patient also had a reaction to Vancomycin. Infectious disease was consulted over the case. The patient was given Benadryl and Vancomycin was continued at a slower rate; ceftriaxone was also continued. During the hospitalization, the patient remained afebrile and hemodynamically stable. Progress note reported that the patient was doing better, and was still on intravenous (IV) antibiotics. The patient was discharged after a period of medical stability. She was instructed to complete a course of antibiotics and follow-up with her obstetrician about a home Zofran pump and intravenous fluids.
 
As per American College of Obstetricians & 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.  

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 intravenous 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, literature indicates that it is important to exclude underlying diseases that can cause hyperemesis.

In this case, this patient had hyperemesis. More importantly, there was some concern about sepsis because of this patient's elevated temperature and cellulitis in the arm. Admission for hydration, intravenous (IV) antibiotics and observation was medically necessary. However the patient was stable. The patient's cellulitis improved. The patient's nausea and vomiting were controlled. The patient was afebrile and the blood cultures were negative. The patient could have been discharged on home infusion.  

The admission was medically necessary for hydration and management of cellulitis. However, after the patient was stable she could have been managed as an outpatient with oral antibiotics and home care. Thus, the complete inpatient admission was not necessary.

The health plan acted reasonably with sound medical judgment and in the best interest of the patient to deny coverage for the last 3 days of inpatient admission. However, the health plan did not act reasonable with sound medical judgment and in the best interest of the patient to deny coverage for the first 3 days of inpatient admission. 

The carrier's denial of coverage for the acute inpatient stay should be modified.