Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting
Treatment: Inpatient Hospital Stay
The health plan denied the requested inpatient hospital stay. 
The health plan's determination is upheld.

The patient is a female with a past medical history significant for hypertension, diabetes mellitus, hyperlipidemia, and substance abuse who presented to the hospital with intractable non-bloody, non-bilious vomiting. She denied fever, chills, diarrhea, constipation, cough, chest pain, shortness of breath, or any other complaints. The patient stated that she was unable to take antihypertensive medications due to excessive vomiting.

At the time the patient was seen by the admitting physician, she was afebrile. The heart rate was 83 beats per minute (bpm), and the respiratory rate was normal. Her blood pressure was 148/92 millimeters of mercury (mmHg), and her oxygen saturation was normal.

The patient appeared to be an obese female who looked fatigued but was in no acute distress. Lungs were clear to auscultation bilaterally. There was a regular rate and rhythm. The abdomen was soft, non-tender, and non-distended. There was no edema. The patient was awake, alert, and oriented times three, with no focal deficits. Laboratory evaluation revealed that the white blood cell count was 11.53, with a hemoglobin of 12.2, a hematocrit of 38.1, platelets of 319, sodium of 137, potassium of 3.8, chloride of 102, a bicarbonate of 22, a blood urea nitrogen (BUN) of 17, a creatinine of 1.08, and a glucose of 218. Liver function tests and lipase were normal.

The patient was admitted to the hospital with hypertensive urgency and vomiting. She was started on intravenous fluids. Treatment with Reglan was initiated. Telemetry monitoring was conducted. It was suspected that the patient's symptoms could be related to marijuana hyperemesis, in combination with diabetic gastroparesis. There was no suspicion of infection.

During the hospital stay, the patient remained afebrile and hemodynamically stable. The oral intake gradually improved, and the patient was transitioned to outpatient care.

At issue is the medical necessity for the inpatient hospital stay.

I uphold, in whole, the health plan's determination of medical necessity.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care. There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at an alternate level of care.

Overall, she remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. At the time of admission and during the entire hospital stay, there was no evidence that the patient had clinical signs of severe infection, severe abdominal pain, or peritoneal signs on exam. There was no evidence of hemodynamic instability. Nausea and vomiting were not persistent and improved within a short period. The patient's symptoms were not associated with severe or profound dehydration or significant electrolyte abnormalities.

The patient was able to tolerate fluids within a short period. The hypertensive urgency that was mentioned at the time of admission is usually not a reason for admission at the acute inpatient level of care.

Taking into consideration all these facts, the admission for observation would have been the most appropriate, to ensure resolution of vomiting, improvement of oral intake, and adequate blood pressure control.

Neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care. The hospital stay was within the scope of an alternate level of care.