This is a patient with a medical history of immune thrombocytopenic purpura, spontaneous subarachnoid hemorrhage, bipolar disorder, and hypothyroidism. She presented to the emergency department with nausea and vomiting for 3 days, including one episode of blood in her emesis, one episode of watery diarrhea, and reduced oral intake. Vital signs were notable for blood pressure of 153/85 millimeters of mercury (mmHg). Lab results showed an elevated aspartate aminotransferase of 72 U/L; platelet count was normal. An x-ray of the abdomen showed a nonobstructive bowel gas pattern.
A Gastroenterology consultation recommended proton pump inhibitor therapy, ondansetron, abdominal ultrasound, and esophagogastroduodenoscopy. She had abdominal burning pain and tenderness documented in one note, and excellent sleep without abdominal pain, nausea, or vomiting or any new complaints per the hospitalist note. Lab results showed an elevated aspartate aminotransferase of 77 U/L and aspartate aminotransferase of 69 U/L. An esophagogastroduodenoscopy (with American Society of Anesthesiologists (ASA) score of III) showed Grade A esophagitis, diffuse gastritis, and duodenitis; biopsies showed chronic active gastritis in the body and antrum, and Helicobacter pylori.

The health plan's determination is upheld. The patient presented with abdominal pain, nausea, vomiting, and diarrhea, as well as one episode of hematemesis. This was consistent with gastritis or gastroenteritis; however, there was no sustained tachycardia or hypotension, ongoing gastrointestinal bleeding, or evidence of pathology such as gastrointestinal perforation, abscess, fistula, peritonitis, sepsis, or bowel obstruction [1-5]. Gastroenterology performed an endoscopy, which was appropriate; and found gastritis but no active bleeding, gastric outlet obstruction, or ulcer. She improved within two days of inpatient admission.

All of the measures that were undertaken, including monitoring, antiemetic therapy, Gastroenterology consultation, and endoscopy, could have been performed without an acute inpatient level of care [2-5]. The patient had gastritis but was not found to have complications such as ongoing gastrointestinal bleeding, gastric outlet obstruction, ulcer, gastrointestinal perforation, abscess, fistula, peritonitis, sepsis, or bowel obstruction.