Appeal type: Medical necessity
Decision: Upheld

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

The patient has a past medical history significant for asthma, non-alcoholic steatohepatitis (NASH), type II diabetes mellitus, and tracheostomy who presented to the emergency department with complaints of a headache, nausea, vomiting, fever, and watery diarrhea. The majority of her symptoms started six days before the presentation, except for diarrhea that started two days before her coming to the hospital.
Upon initial evaluation in the emergency department, the patient was found to be hypoxemic. Her oxygen saturation was 87% on room air and she was placed on a tracheostomy collar.
Subsequently, she became hypotensive and received three boluses of intravenous fluids with an appropriate response. The patient stated to the admitting physician that because of the loss of certain equipment she was unable to suction her tracheostomy at home.
When seen by the admitting physician, the patient's temperature was 100 degrees Fahrenheit (F). The pulse rate was 79 beats per minute (bpm), respiratory rate 19 breaths/minute, blood pressure 105/75, and oxygen saturation was in the range between 87% and 98%.
The patient appeared to be a well-developed, well-nourished individual who was not in acute distress. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), carotid bruits. A tracheostomy was in place, with no drainage. The tracheostomy was not dislodged. The lungs were clear to auscultation with no crackles, rhonchi, or wheezing. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops.
The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. On the neurological exam, the patient was alert and oriented times three. The remainder of the physical exam was unremarkable.
Laboratory evaluation revealed that the white blood cell count was 10.8, hemoglobin 12.6, hematocrit 40, and platelets 333. The sodium was 140, potassium 4.6, chloride 94, bicarbonate 32, blood urea nitrogen (BUN) 9, creatinine 1.15, and glucose 264. The chest x-ray revealed a tracheostomy tube. There was no pneumothorax. There was no evidence of pneumonia or pulmonary edema. From the emergency department, the patient was admitted to the medical floor.
The admitting physician stated that hypoxemia was due to increased tracheal secretions which had been unable to be suctioned at home. The admitting physician stated that the patient had no elevated white blood cell count, was afebrile, and had a clear chest x-ray. Therefore, the decision was made not to continue treatment with intravenous antibiotics including Vancomycin and Azithromycin, which were given in the emergency department. At the same time, the admitting physician decided to continue the administration of Zosyn while checking the procalcitonin level.
It was noted that the patient had abnormal liver function tests (LFTs). An abdominal ultrasound was performed and demonstrated hepatomegaly with steatosis. The gastroenterology service was consulted, however, the patient was not seen by the gastroenterology (GI) attending physician since she elected to leave the hospital against medical advice.
It was also noted that two weeks before the day of admission the patient sustained a fall that resulted in back/flank pain. This was treated with Naproxen and Flexeril with improvement. Apparently, she also had right ankle swelling. Therefore, she was recommended to follow up with an orthopedic surgeon as an outpatient.
At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary.
The patient presented to the hospital with several medical problems including diarrhea, nausea, and vomiting, which were initially associated with hypotension and hypokalemia. These symptoms were attributed to acute gastroenteritis, which is usually a self-limiting condition. The patient's symptoms significantly improved within a short period of time, including improvement in the hypotension. The hypokalemia was relatively mild. The stool studies did not reveal evidence of an infection.
The elevated liver function tests were most likely related to previously diagnosed NASH which was a chronic condition. The patient's hypoxemia was related to increased tracheal secretions and the inability to suction them at home due to a lack of working equipment. After the patient underwent suctioning at the hospital, her hypoxemia resolved.
It was clearly indicated in the notes that the patient was afebrile, had a normal white blood cell count, and an unremarkable chest x-ray. Therefore, there was no need for the administration of intravenous antibiotics beyond the period of observation.
Taking into consideration all of this information, there was no overwhelming evidence that either the severity of the patient's condition or the complexity of the services provided rose to the acute inpatient level of care. Ensuring the resolution of gastrointestinal symptoms and also making sure that the patient's respiratory symptoms and oxygen saturation improved could have been performed at the observation 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. Neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care.