Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 

The insurer denied the Inpatient Stay. 
The denial is overturned. 

The patient is a female with a history of cannabinoid hyperemesis and Helicobacter (H) pylori gastritis that presented to the emergency department (ED) with vomiting. She had given up cannabis use but smoked the day prior followed by eight episodes of vomiting and one episode of diarrhea. Most recent testing for H pylori was negative. Her vital signs included a temperature at 37.4, heart rate was 89, respiratory rate was 18, and blood pressure was 135/87. Examination included no acute distress, moist mucous membranes, benign abdomen, pale skin, and anxious mood. She was treated with Zofran and a normal saline bolus. 
The laboratory evaluation revealed metabolic acidosis with carbon dioxide (CO2) at 19. She failed an oral challenge so was admitted for further management. Admission orders included maintenance intravenous (IV) fluids, clear liquid diet, parenteral Zofran/famotidine/pantoprazole, and sexually transmitted disease (STD) testing. She continued to have vomiting associated with mild epigastric pain. She was unable to tolerate liquids. By day 7 her vomiting had significantly decreased, and she was able to tolerate solids and fluids. She was deemed stable for discharge home with close outpatient follow-up. 

At issue is the medical necessity of the Inpatient Stay. 

The health plan's determination of medical necessity is overturned in whole. 

The requested health service/treatment of Inpatient Stay was medically necessary for this patient. 
An acute inpatient admission was medically necessary for this female teen with cannabinoid hyperemesis until resolution of the vomiting and demonstrated ability to tolerate fluids. She was not safe for discharge prior. Cannabis hyperemesis syndrome has recently become part of the differential diagnosis for patients that present with recurrent vomiting in conjunction with chronic cannabis use. This syndrome is characterized by periodic nausea, vomiting, and abdominal pain. These patients also report frequent and compulsive bathing in hot water because it provides some temporary relief. In between episodes, patients are usually completely asymptomatic. The mechanism is not fully understood, because cannabis has been used as an anti-emetic agent in some populations but may involve decreased gut motility and gastric emptying and overstimulation of the cannabinoid receptor type 1 in the intestine. There is some thought that it may be a subtype of cyclic vomiting syndrome. Rome 4 (IV) criteria for diagnosis include the following: symptoms present for past three months with onset at least six months prior, stereotypical episodes lasting less than a week, at least three episodes in the last year with two episodes in the last six months, and no vomiting in between episodes. Management involves symptomatic treatment and ruling out other causes of recurrent vomiting and abdominal pain. The differential diagnosis includes cyclic vomiting, a syndrome for which cannabis is considered a potential treatment, further complicating this issue. 
This female with history of cannabinoid hyperemesis syndrome presented to the ED after a period of abstinence and then return to cannabis use with intractable vomiting. Despite aggressive fluid, antiemetic, and antacid management, it took a week for her symptoms to resolve. She was not stable for discharge prior because she was not able to tolerate enough oral fluids to sustain herself. The inpatient admission was appropriate.
Therefore, the requested health service/treatment of Inpatient Stay was medically necessary.