Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nausea and vomiting
Treatment: Inpatient hospital admission 
The insurer denied the inpatient hospital admission. 
The denial is partially overturned.

The patient is an adolescent male with a medical history significant for chronic constipation, mild intermittent asthma, H. pylori (Helicobacter pylori) infection, multisystem inflammatory syndrome associated with COVID (Coronavirus 2019), and persistent/recurrent emesis. He presented to the ED (emergency department) with three-week history of vomiting after meals.

The patient's vital signs included temperature 36.5, heart rate 82, respiratory rate 20, and blood pressure 112/56. Examination was significant for no acute distress, non-toxic appearance, moist mucous membranes, regular heart rate, clear lungs, voluntary abdominal guarding, non-tender abdomen, and non-focal neurologic exam. KUB (kidney, ureter, bladder x-ray) was obtained with non-obstructive bowel gas pattern and moderate to large amount of stool throughout the colon. Blood work was unremarkable. Viral screen was negative.

The patient was treated with Zofran and a normal saline bolus followed by IV (intravenous) fluids. Gastroenterology (GI) consult recommended Senna, Miralax, and a Fleets enema for constipation, and Reglan for nausea.

GI recommendations included celiac labs and thyroid studies, additional stool studies, urine toxicology screen, consideration for abdominal ultrasound, Periactin for gastroparesis, and consideration for endoscopy in the setting of persistent vomiting. The ultrasound and labs were unremarkable. Proton pump inhibitor was added. Gastric emptying study was normal. Endoscopy was pending adequate staffing. The diagnosis at this time was rumination syndrome. The patient was taught breathing exercises to improve symptoms. He continued to have some episodes of regurgitation and he was practicing the diaphragmatic breathing. Speech and Language Pathology (SLP) and Psychiatry were consulted for rumination syndrome. Infectious work-up was negative.

The patient was referred to the SLP program and cleared by Psychiatry that recommended outpatient therapy. The endoscopy was completed revealing normal esophagus, no lesions in the stomach, and normal duodenum. He was deemed stable for discharge to follow-up with SLP program, GI, and his primary care practitioner.

The inpatient hospital admission was medically necessary, in part.

Rumination syndrome is a process that involves repeated regurgitation of food with re-chewing or vomiting of food shortly after ingestion. It is considered to be a benign process, but can have significant social consequences. Diaphragmatic breathing is the mainstay of therapy for this condition. Identification and treatment of comorbid conditions is essential because rumination may be used as a means to control discomfort. 

The patient was subsequently discharged when no other source of symptoms could be identified. Because all attempts at outpatient management had failed, it was reasonable to admit for necessary diagnostic studies and treatment. However, he remained in the hospital pending endoscopic evaluation after he had been introduced to diaphragmatic breathing. The hospital stay was medically necessary up until that time of the first documentation of teaching breathing techniques. Thereafter, continued hospital stay was based on availability of endoscopy staff. There were multiple references in the medical record that the endoscopy was not emergent but was medically necessary for the diagnostic process. However, there was no reason this could not be done in an outpatient setting. Based on the submitted information, the hospital stay was medically necessary in part however the remainder was not medically necessary.