Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea and vomiting

Treatment is inpatient admission 	

The insurer denied coverage for an inpatient admission 
 
The denial is upheld

The patient has medical diagnoses of diabetes mellitus type one (DM1), gastroparesis, daily marijuana use, and cannabinoid hyperemesis syndrome. The patient presented to the emergency department (ED) with complaints of abdominal pain, nausea, vomiting, diarrhea, and decreased food intake for three days. The patient presented to the (emergency department) with complaints of abdominal pain, nausea, vomiting, diarrhea, and decrease food intake for three days. The Appeal Letter said that the patient presented to the emergency room (ER) with abdominal pain, nausea, vomiting, diarrhea, and decreased appetite. The patient could not be managed at a lower level of care (LOC), due to the acuity of her presenting illness, need for inpatient intravenous fluids, and intravenous antibiotics. The treating provider ordered and recommended inpatient (IP) hospital admission.

The inpatient hospital admission is not considered medically necessary for the patient. The patient had persistent nausea vomiting from hyperemesis syndrome from cannabinoid. The patient required intravenous (IV) fluids and antiemetics but did not fail the observation level of care for the patients. The patient's blood sugars were elevated but did not have low pH (potential for hydrogen) (acidosis) suggesting diabetic ketoacidosis (DKA). The patient had tachycardia and leukocytosis meeting SIRS (Systemic Inflammatory Response Syndrome) criteria; however, no infectious source was ever found and thus does not meet criteria for sepsis. 

"The introduction of the Sepsis-3 definition is still relatively new to the critical care literature but given the ease of SOFA calculation and high specificity of SOFA (Sequential Organ Failure Assessment) /qSOFA (Quick Sequential Organ Failure Assessment) scores, it is likely to be adopted as a consensus definition for future clinical research. However, as highlighted by Williams et al. (11), one limitation of the new definition is the poor sensitivity of the qSOFA scoring system, which likely excludes its use as a screening tool for early sepsis, the stage in which treatment is most effective. Although the SOFA score has the most prognostic accuracy for in-hospital mortality but which one criteria or qSOFA score has more prognostic accuracy of mortality is not clear yet and it needs more research. In addition, many healthcare facilities currently use the previous sepsis definition as part of emergency room and ICU (intensive care unit) protocol and implementation of the new recommendations will require funding to facilitate amendment of protocols and retraining of healthcare providers." (Marik, et al., 2017). 
"Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are acute metabolic complications of diabetes mellitus that can occur in patients with both type 1 and 2 diabetes mellitus. Timely diagnosis, comprehensive clinical and biochemical evaluation, and effective management is key to the successful resolution of DKA and HHS. Critical components of the hyperglycemic crises' management include coordinating fluid resuscitation, insulin therapy, and electrolyte replacement along with the continuous patient monitoring using available laboratory tools to predict the resolution of the hyperglycemic crisis. Understanding and prompt awareness of potential special situations such as
DKA or HHS presentation in the comatose state, possibility of mixed acid-base disorders obscuring the diagnosis of DKA, and the risk of brain edema during therapy are important to reduce the risks of complications without affecting recovery from hyperglycemic crisis." (Gosmanov, et al., 2021).                                                         

The insurer's denial of coverage for inpatient hospital admission is upheld. Medical Necessity is not substantiated.