Appeal type: Medical necessity
Decision: Upheld

Respiratory System
Inpatient Hospital

The patient is a female with a history of asthma and panic attacks who works at the airport and started experiencing a panic attack spell and had to be laid down and placed on oxygen, which per reports is typical for the patient. She was brought into the emergency department, where her pulmonary status was assessed, and it was stable. She then complained of epigastric squeezing sensation associated with nausea and vomiting. She denied chest pain, dizziness, or palpitations.
Vital signs on arrival included a temperature of 98.7F heart rate of 78, blood pressure of 121/73, and respirations of 16. On exam, the patient is described as well-developed, well-nourished, dry mucous membranes, and a normal cardiopulmonary exam.
The laboratory studies show normal electrolytes and renal function. liver function tests (LFTs) are normal. White blood cell count is 10, with a hemoglobin of 13.6. The chest x-ray was clear for any infiltrates.
The patient was diagnosed with intractable abdominal pain likely secondary to cyclical vomiting syndrome in the setting of marijuana dependence. She was placed on a clear liquid diet, with advancement as tolerated and treated with antiemetic medications as well as Ativan for anxiety. The primary team recommended avoidance of narcotics.
Computed tomography (CT) scan of the abdomen showed no evidence of intra-abdominal pathology.
The following day, the patient was noted to have episodes of bradycardia with heart rates between 43 and 78. Cardiology evaluated the patient, who notes that the patient denies any syncopal events, and was asymptomatic with a low heart rate. Electrolytes were rechecked, and they were stable. Cardiac enzymes were normal. The cardiologist concluded that the bradycardia is likely physiologic in the setting of excess vagal tone from abdominal pain and vomiting. An echocardiogram was also ordered to evaluate the structure and function of the heart, and it was normal.
Also, the patient was seen by gastroenterology as well as pulmonary consultants. The gastroenterologist noted that the patient has dyspepsia and is supposed to be treated with proton pump inhibitor (PPI) for two weeks. They counseled the avoidance of cannabis to prevent hyperemesis syndrome.
The pulmonologist felt that the patient likely has obstructive sleep apnea, and the reason for the consultation was daytime hypersomnolence. She will be set up for outpatient obstructive sleep apnea evaluation.
The patient was discharged in stable condition, with close outpatient follow-up.
The question at hand is whether the above presentation warranted an inpatient medical stay.

The health plan's determination is upheld.

The requested health service/treatment of inpatient stay is not medically necessary for this patient. The presentation can be managed under a lower level of care status.
The patient presents with a panic attack, as well as epigastric pain with nausea and vomiting, consistent with cyclical vomiting syndrome caused by cannabis use. This is a benign presentation, in an individual who has normal laboratory studies, without clinical signs of dehydration. There are no severe electrolyte abnormalities. The patient has no hemodynamic instability with the bradycardia noted on telemetry. She was evaluated by cardiology and had normal cardiac testing without evidence of acute coronary syndrome, hemodynamically unstable cardiac dysrhythmias, or heart blocks. In conclusion, the documentation does not support severe acuity of condition to warrant inpatient hospitalization.