Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history significant for type 2 diabetes mellitus, chronic kidney disease stage V, heart failure with preserved ejection fraction, and a recent cerebrovascular accident (CVA) with residual left-sided weakness who presented to the emergency department with complaints of nausea, vomiting, and decreased oral intake that started 2 days before the presentation.
It was reported that in the emergency department the patient supposedly had black-brown vomitus. Therefore, it was suspected that she could have upper gastrointestinal bleeding, and the gastroenterology (GI) service was consulted. However, the admitting physician stated that the upper GI bleeding was an unlikely diagnosis. The patient had electrolyte abnormalities and she was admitted to the hospital for further evaluation and treatment.
When the patient was seen by the admitting physician she was afebrile. Her blood pressure was 155/75, pulse rate 80 beats per minute (bpm), respiratory rate 18 breaths/minute, and oxygen saturation 93% on room air.
The patient was in no acute distress. She 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, non-tender to palpation, with normal bowel sounds, without guarding or rebound.
The rest of the physical exam was unremarkable. Laboratory evaluation revealed that the sodium was 141, potassium 4.1, chloride 99, bicarbonate 28.7, blood urea nitrogen (BUN) 98, creatinine 5.65, and glucose 218. The white blood cell count was 9.2, hemoglobin 8.0, hematocrit 25.1, and platelets 130. Liver function tests were normal. The magnesium was 2.1, and the phosphorus was 5.3. The patient was admitted with nausea and vomiting.
She was initially kept nothing by mouth (NPO) and received treatment with intravenous fluids and antiemetics. A computed tomography (CT) scan of the abdomen and pelvis did not demonstrate any acute abnormalities.
It was mentioned that the patient had undergone a gastric emptying study, which ruled out gastroparesis. The gastric emptying study was performed because the patient had similar presentations to the hospital in the past. After admission to the hospital, the patient had not experienced any nausea or emesis. Her hemoglobin (H&H) remained stable.
It was suspected that the patient's symptoms were related to increased stool burden as well as polypharmacy. During the hospital stay, the patient tolerated her oral intake.
It was mentioned that the gastric emptying study was unremarkable, and the GI service signed off with a recommendation to have a colonoscopy as an outpatient. Reportedly, during the hospital stay the patient received Lokelma because of mild hyperkalemia.
In the hospital, the patient was seen by a nephrologist who indicated that there were no emergent indications for starting hemodialysis. Her kidney function remained stable, and the patient was transitioned to outpatient care.

Based on the review of the medical records, admission at the acute inpatient level of care was not medically necessary.
The patient presented to the hospital with intermittent nausea and vomiting, which was not related to a complete or partial bowel obstruction. It does not appear that nausea and vomiting led to significant metabolic derangements. At the time of admission, the patient had normal sodium and potassium levels. The metabolic derangements in the form of mild hypernatremia were likely related to underlying chronic kidney disease stage V, and not nausea and vomiting that brought the patient to the hospital. There was no evidence that the patient was severely dehydrated with signs of hemodynamic instability. There was no evidence that the symptoms were related to a serious infection.
It was also mentioned that the patient's creatinine levels remained at the baseline, consistent with chronic kidney disease rather than acute kidney failure. After the patient was started on a diet following the gastric emptying study, she was able to tolerate it. The patient did not need any parenteral nutrition due to the inability to tolerate food.
Taking into consideration all of this information, care could have been provided at a lower level to ensure improved oral intake and to rule out serious reasons for her symptoms.
This coincides with the Milliman Care Guidelines (MCG) Health Inpatient Surgical Care 25th Edition for Vomiting. The patient did not meet the criteria for acute inpatient level of care. Neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care.