Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperemesis Gravidarium.
Treatment: Inpatient Stay.
The insurer denied the inpatient stay.
The health plan's determination is upheld.

This patient is a female who was admitted for indication of frequent nausea and vomiting while pregnant. In this case, the patient is at 13-3/7 weeks gestation who was admitted for hyperemesis gravidarium. The patient was noted to have no pertinent surgical or medical history. The patient had admission vital signs that were normal with a blood pressure of 102/68, heart rate of 85 and a respiratory rate of 18 with 100 percent (%) oxygenation on room air. The patient was noted to be afebrile. There was a normal white count. The patient had mild anemia with a hemoglobin of 9.6 and a hematocrit of 27.7%. Her platelets were normal at 280. The patient had a weight loss of 25 pounds. A Thiamine replacement was given. The patient was started on intravenous (IV) fluids, Compazine, Zofran and Pepcid. She had a basic metabolic panel (BMP) performed for electrolytes. 

This was the patient's 5th emergency room (ER) presentation with complaints of nausea and vomiting during pregnancy. The patient had this over the past two months of the current pregnancy. She was intermittently able to tolerate by mouth (PO) intake. She was on Doxylamine, Zofran and Vitamin B6 or Reglan at home. She had limited relief on this. She had weakness and fatigue. She had mild abdominal cramping. She was also on Macrobid for a prior urinary tract infection (UTI) where the culture was negative. At presentation, she was given IV Zofran. She had a prior cesarean delivery. She had no allergies. She had no smoking, tobacco or illicit drug use. The metabolic panel was normal with a mildly low potassium of 3.4. Her liver functions were normal. She was noted to have a normal amylase and lipase. Plans were made for daily weights. An electrocardiogram (EKG) was planned. She was to be started on Pepcid, Vitamin B6, Benadryl, Zofran and Compazine. 

The health plan, in its determination of medical necessity, has acted reasonably, with sound medical judgment and in the best interest of the patient. 

The patient was noted to be medically stable and without any serious comorbidities. She had normal vital signs without tachycardia or hemodynamic instability at admissions and throughout the stay. The patient also was able to tolerate intermittent intake and had no nausea or vomiting after IV therapy on day 1. 

The patient's admission to acute inpatient level of care was not medically necessary as she did not have any findings of hemodynamic instability, vomiting that is severe or persistent, dehydration that was severe or persistent or severe electrolyte abnormalities requiring inpatient care. She did not have a metabolic disorder that was severe or persistent, abdominal pain, significantly elevated serum transaminases, significantly elevated bilirubin, significantly elevated serum amylase or lipase, coagulopathy, ascites, acute renal failure, significant neurologic finding, fetal compromise, or hydatidiform mole complicating pregnancy. The patient's care could have been performed as outpatient care in the emergency department, rapid treatment site, urgent care center or medical office with IV hydration and nutritional and pharmacologic management. . Based upon the recommendations of the American College of Obstetrics and Gynecology, there would have been no medical necessity for admission to acute inpatient care. 

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