Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea and Vomiting. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

The patient had a past medical history significant for marijuana abuse and an ovarian cyst who presented to the hospital with complaints of intractable nausea and vomiting. Her initial treatment included the administration of Reglan, Zofran, Ativan, and Pepcid with no relief. The patient denied any fever or chills. The review of systems was negative for everything except for the symptoms described above. 

At the time of the initial evaluation, the patient's temperature was 99.1 degrees Fahrenheit (F), heart rate was 65 beats per minute (bpm), respiratory rate 18 breaths/minute, blood pressure 143/79, and oxygen saturation 100% on room air. 
The patient was awake, alert, and oriented times three. She looked chronically ill-appearing. She had moist oral mucosa with no rush. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), carotid bruits. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft, with mild tenderness to palpation in the epigastrium. The patient had normal bowel sounds. 
The rest of the physical exam was unremarkable. 
Laboratory evaluation revealed that serum sodium was 143, potassium 3.7, chloride 108, bicarbonate 26, blood urea nitrogen (BUN) 8, creatinine 0.5, and glucose 111. 
The white blood cell count was 9.7, hemoglobin 13.0, hematocrit 38.9, and platelets 222. Liver function tests were normal. A urinalysis was unremarkable except for some ketones. 

The patient was admitted to the hospital with a diagnosis of nausea and cyclical vomiting. This was attributed to cannabis abuse. The patient received treatment with intravenous fluids and proton pump inhibitors. 

Reportedly, the patient also had some haziness at the medial aspect of the right lung, but no signs of pneumonia. Therefore, no antibiotics were indicated. 
According to the medical records, the patient's clinical condition improved quickly, and the patient was discharged home. 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 was afebrile and hemodynamically stable. The symptoms were likely related to acute gastroenteritis versus cannabinoid hyperemesis syndrome. Both conditions are self-limiting and require mostly supportive care. The physical exam was unremarkable and demonstrated no findings to suggest the presence of a serious medical problem. 
Laboratory evaluation did not demonstrate any clinically significant abnormalities. There was no mention that the patient was unable to maintain oral hydration beyond the observation period. 
There was no mention that the patient required any procedures necessitating admission at the acute inpatient level of care. Overall, she remained in stable clinical condition. 
The hospital stay was very short and the care could have been provided at a lower level.