Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea, Vomiting
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history significant for hypertension, hyperlipidemia, gout, cervical spinal stenosis with myelopathy, and recently performed anterior cervical discectomy and fusion who presented to the hospital with complaints of nausea, vomiting, and generalized weakness for 1 week. His symptoms started on the day of discharge after the surgery.
It was indicated in the history and physical (H&P) note that the patient was able to swallow his medications, however, after he drank a small amount of water, he was vomiting immediately a few minutes later. He was barely able to tolerate solid food but could eat some soft/pureed meals. It was also reported that at home he slid off the bed and fell on the ground. He did not lose consciousness. His wife assisted him to get up. The patient stated that he was feeling off balance but denied any numbness, weakness, slurred speech, or facial drooping. He complained of increased thirst and hoarseness of the voice but denied fever, chills, drooling, choking, vertigo, headache, neck pain or swelling, chest pain, shortness of breath, or dysuria.
Upon initial evaluation in the emergency department, the patient was afebrile and tested negative for coronavirus disease 2019 (COVID-19), respiratory syncytial virus (RSV), and influenza.
On the physical exam, the patient was afebrile. His heart rate was 104 beats per minute (bpm), respiratory rate 17 breaths/minute, blood pressure 136/71, and oxygen saturation 98% on room air. The patient was in no acute distress. He did not look ill-appearing. There was a surgical scar on the neck area without fluctuance or open wounds. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. There was 5/5 strength in the upper and lower extremities bilaterally. The neurologic exam was unremarkable.
Laboratory evaluation revealed that the white blood cell count was 29.1, hemoglobin 10.3, hematocrit 28.4, and platelets 311. The sodium was 133, potassium 4.1, bicarbonate 25, blood urea nitrogen (BUN) 71, creatinine 1.44, glucose 475. alanine aminotransferase (ALT) was 24, aspartate aminotransferase (AST) 49, alkaline phosphatase 49, and bilirubin was normal. The creatine phosphokinase (CPK) was 116, normal.
The patient was admitted to the hospital with nausea, vomiting, hoarseness of the voice, generalized weakness, decreased oral intake, leukocytosis, normocytic anemia, acute kidney injury, and lactic acidosis. Considering his recent surgery, the neurosurgical service was consulted. They recommended proceeding with a computed tomography (CT) scan of the cervical spine, and also neurological (neuro) checks.
The patient was seen by an ear, nose, and throat (ENT) specialist who performed a flexible laryngoscopy. It was suggested that the patient had mild prevertebral soft tissue swelling, which could be postoperative. The fullness shown on fiberoptic endoscopy was attributed to vomiting rather than mechanical issues.
The patient was recommended to have an esophagram to evaluate the esophagus better. The evaluation revealed no esophageal leak. There was no evidence of a hemorrhage or abscess. There was isolated dilation of the left laryngeal ventricle without other evidence of vocal cord paralysis. The patient's symptoms improved after treatment with corticosteroids.
As a result of the treatment with corticosteroids, the patient developed hyperglycemia, requiring initiation of a basal/bolus insulin regimen. Subsequently, the patient and his family were educated on the administration of insulin.
During the hospital stay, it was noted that the patient's hemoglobin dropped significantly from 10 down to approximately 7, however, there were no signs of active bleeding. The gastroenterology (GI) service was consulted and recommended an esophagogastroduodenoscopy (EGD) but the patient could not stay in the hospital any longer. The patient was discharged from the hospital in stable clinical condition.
At issue is the medical necessity of an inpatient stay.

An inpatient stay was not medically necessary, based on the severity of the patient's condition and the complexity of the services provided.
The patient's dysphagia and dystonia improved significantly within the first 48-78 hours after admission after he was given high doses of oral corticosteroids. It was clearly indicated in the progress note that the patient was feeling better and able to tolerate liquids and solids without emesis. His neck pain improved. The patient was awake, alert, and oriented times (x) 3 with no neurologic deficits. His mild kidney insufficiency that was present at the time of admission resolved with hydration. The patient was kept on oral medications.
By that time, it became clear that the patient's symptoms were not related to any kind of infection. A CT scan of the neck showed no evidence of abscess or other fluid collection. The antibiotics that were initiated at the time of admission were discontinued. The patient remained afebrile and hemodynamically stable. The corticosteroid-induced hyperglycemia was reasonably well-controlled and did not lead to glycemic emergencies.
There were concerns based on the patient's complaints at the time of admission and recent history of surgery that required further evaluation. However, the patient's condition improved within a relatively short period of time and the patient did not need any procedures or diagnostic studies that would justify an acute inpatient level of care. Care could have been provided at a lower level than inpatient.