Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting.
Treatment: Inpatient admission.
The insurer denied coverage for an inpatient admission.
The denial is upheld.

This case involves a female who presented to the hospital for abdominal pain, nausea, vomiting, and diarrhea. She had a past medical history significant for hyperlipidemia, diabetes, hepatitis steatosis, and a pancreatic mass. Records indicated the patient had a history of fatty liver and mass or cyst in her pancreas and reported vomiting and loose stools for several months before her admission to the hospital. During her stay at the hospital, there was a concern for severe dehydration and severe liver disease. The patient received intravenous fluids, pain medications, antiemetics, and laboratory testing. Reports indicated the patient required monitoring and work-up for a newly diagnosed pancreatic mass that may have been causing possible biliary obstruction.  The inpatient stay was subsequently denied coverage given that it was determined that there were no records indicating the patient had a severe infection, belly pain, electrolyte imbalance, anemia, or kidney failure. It was also determined that she could receive care in an observation setting and follow-up with her physician or at another clinic.  

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

Literature states that chronic nausea and vomiting result from a variety of pathophysiological processes, involving gastrointestinal and non-gastrointestinal causes.  The Milliman Care Guidelines state that the goal is of stay for an individual with undiagnosed abdominal pain is no more than 1 day. Clinical indications for admission to inpatient care include those patients who have continued hemodynamic instability, severe pain requiring acute inpatient management, peritoneal signs, identification of etiology or findings that require inpatient care to include aortic dissection, bowel perforation, bowel ischemia, visceral organ torsion, intestinal obstruction, for patient's no need evaluation and cannot eat or drink for extended periods of time, for patients who have the inability to maintain oral hydration that persists after observation care, when there is suspected toxic megacolon, bacteremia, or they need to undergo procedure that cannot be performed on an ambulatory basis. In the case of this patient, the information provided for the review stated that she had previously been diagnosed with a fatty liver and a mass or cyst on her pancreas. However, there was no evidence that the patient cannot have been treated on an outpatient or observational basis. She did not have acute symptoms nor was she found to have an emergent need for surgery. Therefore, based upon the provided information, the inpatient admission was not considered a medical necessity for this patient and the health care plan acted reasonably and with some medical judgment and in the best interest of the patient.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for an inpatient admission is upheld. Medical Necessity is not substantiated.