Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea and vomiting
 
Treatment: Inpatient hospital services

The insurer denied coverage for inpatient hospital services.  The denial is upheld. 

This patient is a female who presented in the first trimester of gestation with chief complaints of nausea and vomiting, as well as chest and abdominal pain.  Evaluation for chest pain was negative.  Urine analysis showed a small amount of ketones.  She was hydrated in the Emergency Department (ED) and her electrolytes were repleted.  She was able to tolerate oral intake.  She was seen by a Gynecology consultant who decided to admit her since she had multiple visits to the ED for the same problem.  Note that the patient has been admitted previously for the same issue.  A progress note showed that the patient was tolerating an oral diet and was ambulating and feeling well.  She was discharged later that day.

As per ACOG Practice Bulletin number 52, there are no controlled trials comparing hospitalization with outpatient management of hyperemesis gravidarum.  When a woman cannot tolerate liquids without vomiting and has not responded to outpatient management, hospitalization for evaluation and treatment is recommended.  After the patient has been hospitalized on one occasion and a workup for other causes of severe vomiting has been undertaken, intravenous hydration, nutritional support, and modification of antiemetic therapy often can be accomplished at home.  Nevertheless, the option of hospitalization for observation and further assessment should be preserved for patients who experience a change in vital signs or a change in affect or who continue to lose weight.

According to UpToDate:  Women who are unable to maintain adequate hydration, normal electrolyte levels, and acid-base balance with the initial interventions described above should be admitted to the hospital for intravenous fluids and medications.  Women who have severe vomiting, weight loss, ketonuria, dry mucous membranes, poor skin turgor, dehydration, hypotension, alkalosis from hydrochloric acid loss, hypokalemia, or nutritional deficiencies are admitted to the hospital.  In women with persistent vomiting after hospitalization, it is important to exclude underlying diseases that can cause hyperemesis.

According to the standard of care, hospital admission is appropriate for those with persistent vomiting after replacement fluid and intravenous antiemetic therapy, as well as women who present with abnormal electrolyte levels and acid-base balance.  The decision to admit versus discharge to home needs to be individualized based on the patient's severity of disease, resources, patient compliance, and her ability to obtain and have access to outpatient resources (e.g., home health care, infusion pump for administration of intravenous ondansetron at home, etc).

Based on the above, the inpatient hospital admission was not medically necessary.  This is in accordance with standard of care.  The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. 

The carrier's denial of coverage for the inpatient hospital services is upheld.  The medical necessity is not substantiated.