Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is an adult female with a request for acute inpatient care. The patient has a history of marijuana use, anxiety, depression, PTSD (post-traumatic stress disorder). She presented to the emergency room due to vomiting and abdominal pain. The patient had epigastric tenderness, WBC (white blood count) 16, sodium 131, creatinine 3.8, BUN (blood urea nitrogen) 39, and lactic acid 3.8. She was given fluids for dehydration. She denied fever, chills, chest pain, or any other drug abuse. The epigastric pain was mild, with no GI (gastrointestinal) bleeding. She was treated symptomatically with fluids, Zofran, famotidine. Her temperature was normal, pulse 72, BP (blood pressure) 126/79, oxygenation 96%, lungs clear, repeat abdominal exam was soft and non-tender with normal bowel sounds. Lipase normal. The impression was marijuana induced hyperemesis, volume depletion and pre-renal insufficiency. An ultrasound of the abdomen was normal, no gallstones. Ultrasound of the bladder was normal, post void residual was normal.
On the next day the patient was improved. Her creatinine was back to baseline at 0.6. She was feeling okay, and intravenous fluid was discontinued. She was advised to stop marijuana. She tolerated orals and she was discharged home later in the day. The repeat WBC (white blood count) was normal, BUN 15 (blood urea nitrogen).

The Inpatient Hospital Admission was not medically necessary.

Although the patient had an initial dehydration with elevated creatinine, in less than 24 hours the creatinine was back to normal. The treatment with fluids, Zofran, for a history of cyclic vomiting, did not require acute care and could have been accomplished at a lower level of care. The patient was hemodynamically stable, and she evidenced no fever, no toxic state, no bleeding, no mental status changes, and no acute inflammatory condition. There was a known history of cyclic vomiting, with this being another episode. Once the patient was treated symptomatically, there was no observed protracted vomiting. The repeat creatinine was normal in less than 24 hours. There was no bleeding, no fever, no hemodynamic instability, no need for surgery, and no need for endoscopy. The patient did not require acute care.
Diringer described: "Disturbances of magnesium, phosphate and calcium all may contribute to alterations in sensorium. Hypomagnesemia and hypocalcemia can lead to weakness, muscle spasms, and tetany; the weakness from hypophosphatemia and hypomagnesemia can impair respiratory function. Seizures can be seen in cases with very low concentrations of sodium, magnesium, calcium, and phosphate." No alterations in sensorium, weakness, muscle spasms, tetany, or impaired respiratory function requiring acute care was described in this case. 
There was no severe traumatic brain injury in this case but rather dehydration, a reversible acute illness, rapidly reversible with treatment.
Hutto described: "Dysnatremia is a common finding in the intensive care unit (ICU) and may be a predictor for mortality and poor clinical outcomes. Depending on the time of onset (ie, on admission vs later in the ICU [intensive care unit] stay), the incidence of dysnatremias in critically ill patients ranges from 6.9% to 15%, respectively. The symptoms of sodium derangement and their effect on brain physiology make early recognition and correction paramount in the neurologic ICU [intensive care unit]. Hyponatremia in brain injured patients can lead to life-threatening conditions such as seizures and may worsen cerebral edema and contribute to alterations in intracranial pressure." This patient had a prerenal azotemia that could have been treated at a lower level of care.