Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 

The insurer denied the inpatient admission. The denial is overturned in whole. 

The patient is a male with a past medical history significant for alcohol abuse, diabetes mellitus, and possible liver cirrhosis who presented to the emergency department with complaints of fever and vomiting that had been going on for 3 days. Reportedly, before his presentation to the emergency department, the patient recently returned from a long trip. He visited multiple countries where he ate at local restaurants. 

Generally, the patient was awake, lying in bed comfortably, in no acute distress. He had a regular heart rate and rhythm, without murmurs, rubs, or gallops. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. There was no lower extremity edema. The patient was awake, alert, and oriented 3, responded appropriately to questions, and followed commands. His speech was fluent. 

Computed tomography (CT) scan of the head was unremarkable. Abdominal ultrasound revealed no shadowing gallstone or gallbladder wall thickening. 
The patient was admitted and multiple diagnostic tests were ordered. The patient was seen by an infectious disease specialist who stated that the patient's symptoms could be related to viral infection. However, considering his extensive recent travel history, the infectious disease specialist recommended treatment with antibiotics at least initially. 
Subsequently, the treatment with antibiotics was discontinued, and according to the discharge summary, it was determined that the patient's symptoms were most likely related to gastroenteritis or gastroparesis. 

The patient's symptoms gradually improved. Before discharge, the patient was given a prescription for lisinopril to achieve better control of high blood pressure. Since the patient's clinical condition normalized, he was discharged home. 

The health plan's determination is overturned in whole. 

The inpatient hospital admission was medically necessary for this patient. The severity of the patient's condition defined by persistent dehydration due to continuous difficulties with adequate oral intake, as well as the complexity of the services provided, significantly increased the intensity of care justifying the inpatient hospital admission. 
The patient presented to the hospital with complaints of fever and vomiting. At the time of admission, the patient was found to be dehydrated with hyponatremia and acute kidney injury. He was appropriately started on intravenous fluids, with subsequent resolution of his acute kidney injury and hyponatremia. 
However, even though the patient's symptoms improved over the course of the first 2 days of hospitalization, his oral intake was still severely diminished. 
It was clearly indicated in the progress note written that the patient was unable to tolerate oral intake and still required continuous hydration with intravenous fluids. 
Another complicating factor was persistent hyperglycemia that contributed to dehydration. 

Unfortunately, despite multiple explanations, the patient refused to take any medications aimed to achieve better glycemic control. 

In the setting of poor oral intake and persistent hyperglycemia, the patient had a significantly increased risk of worsening dehydration, therefore he required continuous administration of intravenous fluids. 
The acute inpatient level of care was justified not because of the acute gastroenteritis, which contributed to the patient's symptoms, but mostly because of the persistent inability to have an adequate oral intake, persistent hyperglycemia in the setting of medical noncompliance, and the patient's resistance to initiate treatment of uncontrolled diabetes mellitus, which was completely justified in these circumstances.