Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroesophageal Reflux Disease (GERD)

Treatment: Hospital admission

The insurer denied coverage for the hospital admission.

The denial is upheld.

This female patient has a past medical history of chronic gastroesophageal reflux disease (GERD)/gastritis and is being worked up for rheumatoid arthritis.  The patient presented to the Emergency Department (ED) with subjective complaints of right upper quadrant pain and vomiting. The patient reported that her pain had gotten significantly worse over the prior two days. The patient had gone to her gastroenterologist (GI) who recommended a computed tomography (CT) scan of the abdomen and colonoscopy.  When the patient's pain worsened, her GI provider recommended an ED evaluation.  The patient reported several episodes of retching, with small amounts of non-bloody vomitus, but no diarrhea.  The patient admitted to having chills.  The patient was a current daily smoker.  The patient's physical examination revealed tenderness in the epigastric region and right upper quadrant.  The patient's CT scan of the abdomen and pelvis revealed no significant diverticular disease; there was abundant stool throughout the colon.  The patient was status post cholecystectomy.  She noted that she was still nauseous and could not tolerate oral intake.  The patient was admitted for intractable abdominal pain.  There was no leukocytosis noted on patient's bloodwork and her vital signs were normal.  The gastroenterology consultation noted that the patient recently had an esophagogastroduodenoscopy (EGD) and was placed on a proton pump inhibitor twice a day.  There was a large fecal residue seen on a CT scan.  The physician noted suspicion for opioid induced constipation (OIC).  The patient was on a full liquid diet and it was to be advanced as tolerated.  The patient was recommended to have an outpatient gastric emptying study (GES) and colonoscopy.  The patient was treated with intravenous (IV) Dilaudid and was restarted on oxycodone.  Per the staff, the patient was noted to have bottles of her opioid medications at home and was advised not to take them.  The patient did not agree with the recommendations for opioid management, and left against medical advice (AMA).

Based on the review of the medical record, this patient presented to the hospital with nausea and vomiting of unknown etiology.  The patient's CT scan of abdomen and pelvis was unremarkable.  There was no significant laboratory abnormality, no peritoneal signs or acute abdomen, and there were no sign of sepsis, signs of withdrawal, or end organ damage or abnormality that warranted inpatient level of care.  The patient could have received IV fluids and IV nausea medication in an alternative setting, such as observation status.  As per literature review, patients that need hospitalization are those with the following signs and symptoms: significant volume depletion/dehydration, altered mental status, significant rectal bleeding, severe unrelenting abdominal pain, comorbidities such as human immunodeficiency virus (HIV) and diabetes (immunocompromised status), senior adult, recent hospitalization or antibiotics, pregnancy, or weight loss. In this case, there was no fever or severe abdominal pain requiring hospital admission. 

The patient's bloodwork showed no electrolyte abnormality, acid/base derangement, or renal impairment that required inpatient level of care.  Hydration, intravenous nausea medications, and monitoring in an ambulatory setting would have been medically appropriate for this patient and would not have jeopardized her well-being.  Thus, inpatient admission was not medically necessary for this patient.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

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