Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain and Coffee Ground Emesis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with history of asthma, left nephrectomy, history of nephrostomy status post deep vein thrombosis (DVT) with inferior vena cava (IVC) filter placement, history of gastrointestinal (GI) bleed, history of venous stasis, and chronic venous leg ulcer, history of bilateral amputation of toes both feet, history of smoking, cocaine and marijuana abuse, and schizoaffective disorder. The patient presented to the emergency department with nausea, vomiting and hematemesis. The vomit was coffee ground emesis and associated with left upper abdomen crampy pain. 

In the emergency department, the patient was hemodynamically stable and afebrile. He was admitted to the hospital with the diagnosis of upper gastrointestinal (UGI) bleed and cannabis hyperemesis syndrome. He was made 'nothing by mouth' (NPO), and started on intravenous (IV) fluids, IV Protonix 40 milligrams (mg) twice daily (BID) and Zofran. The patient's complete blood count (CBC) was normal. His comprehensive metabolic panel (CMP) revealed mild hyponatremia with sodium (Na) 134, and elevated blood urea nitrogen (BUN) and Creatinine 30/3.32. Because of his history of renal insufficiency, renal ultrasound was ordered and showed no worsening of mild hydronephrosis. The urine analysis was normal. His renal function improved with hydration. Because of his prior history of cellulitis of the leg and leg ulcer, he was continued with oral antibiotics. 

The next day, the patient felt better, and tolerated diet well. The psych consult was done for schizoaffective disorder, and as per their recommendation, the patient was stable from Psych standpoint. The gastroenterology (GI) consult was done and since the patient was hemodynamically stable, outpatient esophagogastroduodenoscopy (EGD) was recommended. The patient was discharged home with an outpatient follow up with GI and his primary care physician (PCP).

No, the proposed acute level of care for the management of this patient's condition of upper gastrointestinal (UGI) bleed was not medically necessary. 

The patient presented with one day history of crampy upper abdominal pain and coffee ground emesis with no hemodynamic instability. His hemoglobin (Hb)/hematocrit (HCT) were stable. He has prior history of chronic kidney disease secondary to nephrectomy and had acute kidney injury superimposed upon on chronic kidney disease for which he was treated with intravenous (IV) hydration. His renal ultrasound was remarkable for mild hydronephrosis which was unchanged from before. He was started back on his oral antibiotics for left leg cellulitis and ulcer. He was started on intravenous (IV) Protonix and Zofran and IV fluids, and gastroenterology (GI) consult was done and endoscopy was recommended as an outpatient. The patient remained hemodynamically stable throughout his hospital stay and did not require any blood transfusion. He was discharged home in a fair and stable condition with outpatient follow up for endoscopy. Given this clinical scenario, the patient care could have safely provided at the lower level of care.