Diagnosis: Vomiting, nausea, epigastric pain

Treatment: Inpatient Admission

The insurer denied the inpatient admission. The denial was upheld.

This is a male patient who has a medical history of liver disease and substance abuse. He presented with nausea and vomiting. He was also having epigastric pains. He was afebrile and the vital signs were stable. There were no peritoneal signs. There was no leukocytosis. The renal function was normal. Computerized Axial Tomography (CAT) scans were negative for acute disease. He was treated with a proton pump inhibitor (PPI), intravenous (IV) hydration and Zofran and he improved.

Clinical indications for admission for vomiting (M-370) include intestinal obstruction or a significant metabolic derangement. The patient did not have these conditions. He also did not have hemodynamic instability, bacteremia, high fevers, or acute renal failure.
This patient had vomiting and epigastric pain. However, he responded to treatment with IV hydration, Protonix, and Zofran. He could have received this treatment with observation status. He did not meet MCG criteria for admission for vomiting. The healthcare plan acted reasonably and with sound medical judgment and in the patient's best interest. An inpatient admission was not medically necessary. The denial is upheld.

The carrier's denial of coverage for the inpatient hospital admission is upheld. The medical necessity is not substantiated.