Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Emesis and decreased appetite
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a female with no known significant past medical history, presenting to the emergency room with several days of emesis, and decreased appetite. The patient had one temperature of 100.7. The patient did not have any inconsolable crying, did not have any seizure activity, did not have any change in mental status, did not have any neck stiffness or photophobia, the patient did not have any blood in stool, and the patient was noted to be arousable. The patient was also noted to have a normal urine output. 

Upon presenting to the emergency room, the patient was noted to have difficulty tolerating by mouth (PO), with being sleepy but arousable. There was no noted decrease in tone, no difficulty in arousability, and no notation of general exam that was concerning for lethargy. The patient's lab values were significant for mild hyponatremia, and a decreased sodium bicarbonate level. The patient also had an elevated heart rate with positive ketones in urine. The specific gravity in the urine was not concerning, and the glucose was also within normal limits. Kidney function was not concerning as for the lab reports. There was no concern for cerebral edema, decreased respiratory function, or any other concerning symptoms of shock. There is no documentation of failed by mouth (PO) challenge with ondansetron in the emergency room. The patient was treated with intravenous fluids and clinical monitoring and was discharged when tolerating by mouth.

No, the proposed inpatient admission was not medically necesary.
Upon reviewing the included documentation, the patient did not have vitals or an assessment or lab work consistent with some of the terminology used to describe her level of illness and care requirements.  The patient was described as sleepy but arousable.  The patient was not noted to be difficult to wake, inconsolably crying, or in any distress.  This assessment is not consistent with lethargy.  The patient had mild hyponatremia.  The sodium (Na) level of 131 was treated with normal saline (NS) fluid, no hypertonic fluid was needed.  The blood urea nitrogen (BUN) / creatinine (Cr) levels were not concerning for impending renal failure or severe dehydration.  Bicarb level of 13 and urine specific gravity of 1.022 were also consistent with mild dehydration.  No notation of poor skin turgor, cap refill greater than (>) two seconds were noted.  The patient was treated with intravenous (IV) fluids, normal saline, and was then able to be discharged.

The patient had no concern for symptoms of cerebral edema, seizures or decrease in respiratory effort or rhabdomyolysis.  No water restriction was incorporated into the plan. No other monitoring or care consistent with a lethargic, severely hyponatremic patient was described.  The patient had mild dehydration, with mild hyponatremia and was treated as such.  The patient did not require inpatient level care, rather observation level care was medically appropriate. 

Yes, the health plan has acted with sound medical judgement. Inpatient level of care was not medically necessary; observation level of care was medically appropriate.