Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intractable emesis. 
Treatment: Full hospital admission. 
The insurer denied coverage for the full hospital admission. 
The denial is upheld. 

The patient had intractable emesis. The insurer has denied coverage for the full hospital admission, as not medically necessary. In a Final Adverse Determination letter, they stated that the patient presented to the hospital with dehydration. There were no severe problems warranting a full hospital admission. The requested admission is denied based on Milliman Care Guidelines 26th Edition using the guideline of Dehydration (ORG: M-123).

The three day history of abdominal pain, fever, and chills. The patient was given an intravenous (IV) fluid bolus, IV Pepcid, IV Toradol, and IV Fentanyl. Symptoms persisted. The patient was admitted with intractable vomiting and gastroenteritis. The care plan consisted of IV fluids, polymerase chain reaction (PCR)  and stool for occult blood, IV Zofran every 6 hours (Q6H), an electrocardiogram (EKG), nothing by mouth (NPO), and advancing the patient's diet as tolerated. The patient was discharged. 

Despite the patient's presentation the care as provided could have been rendered in its entirety at a lower level of care. The patient had an infection; yet the patient did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. As such, the care could have been rendered at a lesser level. 

"Acute gastroenteritis (AGE) is broadly defined as inflammation of the stomach and intestine due to an infectious cause, generally presenting with diarrhea and vomiting, fever, and abdominal pain;1,2 however, there is no universal definition of the specific clinical criteria that correlate with this disease entity... 

Many common exposures increase the risk of developing AGE, such as domestic or international travel to areas with poor sanitation practices; antibiotic use; exposure to zoonoses; and time spent in healthcare settings, long-term care facilities, and childcare settings. Host features also play a significant role, particularly immunosuppression (due to medication or primary disease) and vaccination status. A careful history is essential to risk stratify patients." (Geyer B. 2020). 

Many common exposures increase the risk of developing AGE, such as domestic or international travel to areas with poor sanitation practices; antibiotic use; exposure to zoonoses; and time spent in healthcare settings, long-term care facilities, and childcare settings. Host features also play a significant role, particularly immunosuppression (due to medication or primary disease) and vaccination status. A careful history is essential to risk stratify patients." (Geyer B. 2020). 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the full hospital admission on is not substantiated.