Appeal type: Medical necessity
Decision: Upheld

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

The insurer denied inpatient stay. 
The denial is upheld. 

The patient is a female with a past medical history significant for asthma who presented to the emergency department with complaints of nausea, vomiting of dark brown material that was associated with abdominal pain, watery diarrhea. Her symptoms started acutely on the day of admission. 
The patient endorsed using two joints of marijuana daily. She smoked four cigars daily, and occasionally drank alcohol. 
A review of systems was negative for fever, chills, congestion, or drooling. It was positive for abdominal pain, nausea, vomiting, and diarrhea. The patient denied any abdominal distention, rectal bleeding, blood in the stool. The rest of the review of systems was negative. 
Laboratory evaluation revealed that the patient was afebrile. Blood pressure was 142/112, respiratory rate 17 breaths/min, oxygen saturation 100% (percent) on room air.
The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The patient had a regular rate and rhythm, without murmurs, rubs, or gallops. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The bowel sounds were normal, and the abdomen was soft. The rest of the physical exam was unremarkable. 
Laboratory evaluation revealed that white blood cell count was 22.7, hemoglobin 14.8, platelets 254. The sodium was 142, potassium 5.2, chloride 100, bicarbonate 22, blood urea nitrogen (BUN) 14, creatinine 0.66, glucose 155. Magnesium was 1.9, phosphorus 4.1. Alanine aminotransferase (ALT) was 24, aspartate aminotransferase (AST) 41, and alkaline phosphatase 66. 

The patient was admitted to the hospital with suspicion for marijuana hyperemesis syndrome. The patient received treatment with intravenous fluids, and antiemetics. Another clinical diagnosis was leukocytosis. The admitting physician indicated that the patient had elevated white blood cell count during previous admissions. In addition, the admitting physician stated that the patient's urinalysis and chest x-ray were negative. The elevated blood pressure was attributed to stress. 
During the hospital stay, the patient's clinical condition significantly improved. Nausea and vomiting resolved. The final diagnosis was cyclic vomiting syndrome. 
Since the patient's clinical condition significantly improved, she was transitioned to outpatient care. 

The health plan's determination is upheld. 

The inpatient stay was not medically necessary for this patient. 

The review of the medical records demonstrated that the patient's symptoms were not associated with severe infection. There was no mention that the patient was immunocompromised or had severe diarrhea. 
The was no evidence of peritoneal signs on the abdominal exam. The patient remained hemodynamically stable during the entire hospitalization. There was no evidence of severe dehydration, kidney failure, or electrolyte abnormalities. The patient's symptoms improved within a short period of time, and she was able to maintain oral hydration. 
Taking into consideration all these facts, neither the severity of the patient's condition nor the complexity of services provided rose to the acute inpatient level of care. 
Overall, this patient remained in a stable clinical condition. Her symptoms improved relatively fast. The patient did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. 
The hospital stay was very short and could have been managed at a lower level of care status.