Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal - Hyperemesis. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is overturned.

The patient is a female with a history of hyperemesis cannabinoid syndrome who presented with emesis and diarrhea.
She was in her usual state of health until the night prior to presentation when she developed emesis and diarrhea. She described this as a recurrent issue related to her marijuana use and had last smoked marijuana 2 days previously. She was taking antibiotics for Helicobacter (H.) Pylori infection as well as Pepcid, but frequently forgets to take the medications. She also noted weakness and tingling of her hands and feet. She attributed all of these symptoms to marijuana withdrawal.
In the emergency department, her temperature was 38.4 Celsius (C) and her heart rate was 92 beats per minute (bpm). She was described as being in moderate discomfort and she was noted to be actively retching and vomiting bilious content. Laboratory values were obtained which revealed a glucose of 163, a sodium of 132, and a bicarbonate of 17. A chest x-ray was also obtained. She was given intravenous famotidine and ondansetron as well as a normal saline bolus. She was subsequently admitted to the hospital for management of cannabinoid hyperemesis syndrome, with dehydration secondary to recurrent vomiting and diarrhea.
On admission, she continued to vomit several times. She was kept on intravenous fluids, Pepcid, and diphenhydramine as needed (prn). She continued to vomit the next morning and her treatments continued. The following day, her vomiting had resolved. She was able to tolerate oral intake at that time and was felt to be stable for discharge to home with follow up with psychiatry.
The medical necessity for the inpatient stay is under review.

The health plan's determination is overturned.

This is a patient who presented with hyperemesis and dehydration. She was in discomfort at the time of presentation and was actively vomiting. She was dehydrated with a bicarbonate level of 17 and was unable to rehydrate orally due to continued vomiting. She therefore required hospital admission for continued administration of intravenous fluids and Pepcid, along with continuous monitoring.
Patients with cannabinoid hyperemesis syndrome can present with severe nausea and vomiting and abdominal pain. Acute treatment consists of symptomatic care including intravenous fluid hydration and antiemetics. Patients must also be evaluated for other etiologies for the symptoms or potential complications of excessive vomiting. This patient presented with hyperemesis with continued vomiting and dehydration despite appropriate treatment in the emergency department setting. Therefore, she required hospital admission for continued evaluation and treatment with intravenous therapies. 
The decision making at the time of admission for this patient was consistent with her  age, the presence of hyperemesis with continued active vomiting and dehydration, and the need for ongoing intravenous therapies along with close monitoring for potential deterioration of clinical status.