Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stomach and/or Bowel Problems and Vomiting
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a adolescent female with medical history significant for gastroesophageal reflux, esophagitis, Helicobacter (H) pylori infection and gastritis diagnosed via endoscopy, and social history significant for daily marijuana use that presented to the emergency department with six-day history of recurrent vomiting and abdominal pain. The pain was epigastric in location and rated eight out of ten (8/10). She had been seen in the emergency department the day prior with similar complaints, managed with Zofran, famotidine, alum and magnesium hydroxide, and discharged home with treatment for Helicobacter pylori (amoxicillin, clarithromycin, pantoprazole). She was unable to take the prescribed medications due to vomiting. 

The patient was febrile in the emergency department with temperature 38.4, heart rate 120, respiratory rate 18, and blood pressure 142/84. Examination was significant for moderate distress due to epigastric pain, actively vomiting, tachycardia, epigastric tenderness, no guarding or rebound, and non-focal neurologic exam. Accu-Chek was 98 mg/dL (milligrams per deciliter). Laboratory evaluation was significant for metabolic alkalosis on venous blood gas with potential of hydrogen (pH) 7.61 and partial pressure of carbon dioxide (pCO2) 21.5, normal amylase, metabolic acidosis with carbon dioxide (CO2) 19, mildly elevated transaminases (aspartate aminotransferase [AST] 54, alanine aminotransferase [ALT] 60), unremarkable white blood cell count and C-reactive protein (CRP), and concentrated urine with ketones and blood (on menses). Rapid influenza testing was negative. She was treated with Zofran, lidocaine viscous solution, famotidine, antacid, Tylenol, and three normal saline boluses. She failed an oral challenge, with persistent vomiting. She was admitted for ongoing management of intractable vomiting. 

Admission orders included routine vitals, maintenance intravenous (IV) fluids, clear liquids, Protonix, Zofran as needed, antipyretics, and Gastroenterology consultation. Despite aggressive hydration and anti-emetics, she continued vomiting. Ativan provided some relief, but she was still not able to tolerate anything by mouth. She was evaluated by Gastroenterology with diagnosis of cannabinoid hyperemesis syndrome and gastritis. Recommendations included cyproheptadine, stool for Helicobacter pylori antigen, and discontinue Ativan. The following day, she was able to start eating, tolerating a regular diet by dinner. She passed the first stool since admission, sent for Helicobacter pylori testing. She was stable with no fever, vomiting, or abdominal pain. She was deemed stable for discharge.

Yes, acute inpatient admission was medically necessary.

Cannabis hyperemesis syndrome has recently become part of the differential diagnosis for patients that present with recurrent vomiting in conjunction with chronic cannabis use. This syndrome is characterized by periodic nausea, vomiting, and abdominal pain. These patients also report frequent and compulsive bathing in hot water because it provides some temporary relief. In between episodes, patients are typically completely asymptomatic. The mechanism is not fully understood because cannabis has been used as an antiemetic agent in some populations, but may involve decreased gut motility, gastric emptying, and overstimulation of the cannabinoid receptor type I in the intestine. Rome IV criteria for diagnosis include the following: symptoms present for past three months with onset at least six months prior, stereotypical episodes lasting less than a week, at least three episodes in the last year with two episodes in the last six months, and no vomiting in between episodes. Management involves symptomatic treatment, ruling out other causes of recurrent vomiting and abdominal pain. The differential diagnosis includes cyclic vomiting, a syndrome for which cannabis is considered a potential treatment, further complicating this issue. 

This female teen presented to the emergency department for the second time with intractable vomiting, epigastric pain, and fever. With history of gastritis, esophagitis, positive Helicobacter pylori testing, and cannabis use, the differential diagnosis was quite broad. She failed an oral challenge in the emergency department, with continued vomiting and pain. Her symptoms eventually resolved, allowing for safe discharge home. She failed outpatient treatment twice, as well as observation in the emergency department. The care that she was given in the hospital was most consistent with acute inpatient management. She could not have been appropriately managed at a lower level of care.