Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperemesis Gravidarum
Treatment: Full hospital admission
The insurer denied: Full hospital admission
The denial is: Upheld

This patient is a gravida (G)3 para (P)1 abortion (A)1 female who was admitted to the hospital with a diagnosis of hyperemesis affecting pregnancy and a urinary tract infection. The patient was noted to be 15 weeks gestation at time of presentation. She reported a loss of 20-25 pounds over the past couple of months due to the inability to eat or drink. The patient noted that she tolerate only about 1-2 Gatorade drinks per day. She underwent an ultrasound the obstetrics/gynecology (OB/GYN) office prior which showed normal development of the pregnancy with a fetal heartbeat. The patient reported that her urine was dark in color, and she denied any dysuria. The patient reports that her obstetrician was attempting to get approval for Zofran. The patient had no fever, gastrointestinal (GI) bleed, headache, visual disturbances, chest pain, dyspnea, dysuria, recent travel or sick contacts. The patient was 15 weeks pregnant on presentation. The patient's review of systems was noted to be totally negative with exception of those mentioned above.
The patient was formally admitted at 14-6/7 weeks with nausea and vomiting of pregnancy and inability to tolerate intake. The subject under review is the medical necessity for the full hospital admission.

Based upon review of the medical records, the peer reviewed literature, American College of Obstetricians and Gynecologists (ACOG) recommendations and Milliman Care Guidelines (MCG) Care Guideline entitled "Hyperemesis Gravidarum" there would not be medical necessity for full inpatient hospital admission. In this case, the patient was noted to be 15 weeks pregnant with nausea and vomiting of pregnancy. She had a normal potassium of 4.1-4.2 and mild hypomagnesemia. These were replaced by IV with lactated ringers at 125 cubic centimeters (cc)/hour as intravenous (IV) fluids. The patient had stable vital signs and clinically was described as stable without any acute findings during physical exam. There was no tachycardia, acute abdominal findings, or metabolic derangements indicating the need for admission. In this case, the presentation is evaluated in concert with the MCG Health Inpatient & Surgical Care 25th Edition Guideline entitled Hyperemesis Gravidarum. Based upon evaluation of these criteria against the medical records, the patient had none of the criteria for inpatient admission met. The patient was noted to have no ongoing vomiting in the emergency department and also only had no ongoing vomiting based upon the daily physician assessments. The patient was noted not to have severe or persistent vomiting. Her vital signs remained stable. There was no vomiting due to significant metabolic derangements in this case as her potassium was normal. The patient had no other presentation requiring admission to acute inpatient level of care such as pain. The patient had no renal failure and was not on parenteral nutrition. Based upon evaluation, the patient would not be indicated for admission to acute inpatient level of care. The patient would be appropriate for a lower level of care status. This is in agreement with the recommendations of ACOG. ACOG would endorse a lower level of care status as well in this case. In this case, the patient could have been safely and appropriately treated at a lower level of care status and would not have required acute inpatient level of care for her management in this case.