Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Hyperemesis Gravidarum, first trimester
Treatment inpatient admission
The insurer denied coverage for inpatient admission
The denial is modified.

The patient is a female with a possible history of renal disorder. She presented to the emergency department for emesis for the past month. The patient has been in and out of ER (emergency room) because of nausea and vomiting. She reported abdominal pain, nausea, and vomiting. She was 11.4 weeks pregnant. Ketones in urine was positive. Potassium was elevated (specimen was hemolyzed). The patient was previously prescribed Zofran but has not taken it for 3 weeks prior to admission because she ran out of it. The patient was hydrated and transitioned to regular diet. She was also diagnosed with a urinary tract infection and treated with antibiotics. Progress notes stated that the patient was tolerating oral intake. She was later discharged.

As per ACOG (American College of Obstetricians and Gynecologists), 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. Nevertheless, the option of hospitalization for observation and further assessment should be preserved for patients who experience a change in vital signs or a change in affect or who continue to lose weight.
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.

The decision to admit versus discharge to home needs to be individualized based on the patient's severity of disease, resources, ability to comply with the management plan, and ability to obtain and have access to outpatient resources.

This patient has been evaluated previously during multiple emergency department visits. She was prescribed Zofran with good response but ran out of it.

On presentation, she was tachycardic with evidence of dehydration (large ketones in urine). There was no evidence of alkalosis or hyperkalemia.

The patient was adequately hydrated. According to progress notes, she was tolerating diet. While still complaining of nausea, and very few episodes of vomiting, the patient was stable and could have been discharged home followed closely as an outpatient.

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

The insurer's denial of coverage for an inpatient admission is modified. Medical Necessity is medically necessary for the first and second day but uphold the denial for continued stay as not medically necessary. Medical necessity is partially substantiated.