Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperemesis gravidarum.
Treatment: Inpatient Hospital Admission.

The insurer denied coverage for the Inpatient Hospital Admission.  The denial is modified. 

This is a female patient at 11 weeks gestation who presented to the Emergency Room with complaints of a 5 week history of vomiting.  She took Zofran at home without relief.  Intravenous (IV) fluids and IV Zofran were given.  Her sodium level was low.  The patient was admitted with hyperemesis gravidarum.  The plan was to continue IV fluids, administer 16 milligrams (mg) of IV methylprednisolone every 8 hours (Q8H), and continue a lab workup.  Potassium level was low and potassium was replaced.  She had a urinary tract infection (UTI) and was given IV Cefazolin.
  
Progress note on day 2 of admission noted the patient was stable, vomited once, with normal vital signs and laboratory results. Progress note on day 3 of admission noted the patient was stable, vomited once, with normal vital signs and laboratory results. She was discharged on day 4 of admission after she was able to tolerate a regular diet without vomiting.

As per The American College of Gynecology (ACOG), there are no controlled trials comparing hospitalization with outpatient management of hyperemesis gravidarum.  When a woman cannot tolerate liquids without vomiting and has not responded to outpatient management, hospitalization for evaluation and treatment is recommended.  After the patient has been hospitalized on one occasion and a workup for other causes of severe vomiting has been undertaken, intravenous hydration, nutritional support, and modification of antiemetic therapy often can be accomplished at home. Nevertheless, the option of hospitalization for observation and further assessment should be preserved for patients who experience a change in vital signs or a change in affect or who continue to lose weight.

According to UpToDate: Women who are unable to maintain adequate hydration, normal electrolyte levels, and acid-base balance with the initial interventions described above should be admitted to the hospital for intravenous fluids and medications.  Women who have severe vomiting, weight loss, ketonuria, dry mucous membranes, poor skin turgor, dehydration, hypotension, alkalosis from hydrochloric acid loss, hypokalemia, or nutritional deficiencies are admitted to the hospital.  The decision to admit versus discharge to home needs to be individualized based on the patient's severity of disease, resources, ability to comply with the management plan, and ability to obtain and have access to outpatient resources.

This patient presented with nausea and vomiting. She was stable.  She had electrolyte imbalance, hypokalemia, but no nutritional deficiencies.  Admission was medically necessary for hydration, and stabilization of electrolytes.  However, as of day 2 of admission she was tolerating oral intake, and her electrolytes had stabilized.  She could have been discharged home and followed up as an outpatient.

The health care plan did not act reasonably with regard to the admission; they did act reasonably with regard to the continued stay.

The carrier's denial of coverage for the Inpatient Hospital Admission is modified. Allow day 1 of admission, but deny the ongoing inpatient stay from day 2 of admission forward.