202003-126355
2020
Empire Healthchoice Assurance Inc.
Indemnity
Digestive System/ Gastrointestinal
Inpatient Hospital
Medical necessity
Upheld
Case Summary
Diagnosis: Gastroparesis
Treatment: Inpatient hospital stay
The insurer denied coverage for inpatient hospital stay.
The denial is upheld.
This patient is a female with a past medical history of hyperlipidemia, hypertension, hypothyroidism, asthma, chronic obstructive pulmonary disease (COPD) Graves' disease, depression, anxiety, gastroparesis (status post gastric pacemaker placement), status post appendectomy, cholecystectomy, and thyroidectomy. The patient presented to the emergency department with nausea, vomiting, abdominal pain, and diarrhea. The patient's blood pressure was 155/118 and her saturations were 99% on room air. The temperature was 97.3°F. The abdomen was soft and non-distended. There was no rebound and no guarding. There was generalized pain on palpation. There were no bowel sounds in all 4 quadrants. The patient's white blood cell count was 13.53 and her lactate was 1.3. Her lipase was 33.
The patient was treated with intravenous fluids, morphine, and Zofran. The patient was given Dilaudid for pain without improvement. The patient refused to drink contrast for a CT scan. The provider indicated that the patient had a medical necessity beyond the capabilities of an emergency department and there was a concern for intractable vomiting. The patient was admitted with a diagnosis of intractable vomiting. The patient was initially treated with nothing by mouth and was seen by Gastroenterology. The patient was treated with intravenous pain medications and multiple doses of Zofran. The patient's diet was advanced on and she was discharged.
This patient was admitted with a diagnosis of probable gastroparesis. She showed no signs, symptoms, or laboratory data to suggest toxicity or criteria to warrant hospital admission as inpatient rather than observation. Patients that need hospitalization are those with the following signs and symptoms: Volume depletion/dehydration, altered mental status, significant rectal bleeding, prolonged symptoms (more than a week), severe abdominal pain, comorbidities such as HIV and diabetes (immunocompromised status), age >=65 years, recent hospitalization or antibiotics, pregnancy, or weight loss.
The inpatient hospital stay was not medically necessary. The health plan acted reasonably with sound medical judgment in the best interest of the patient.
Based on the above, the medical necessity for the inpatient hospital stay from is not substantiated. The insurer's denial is upheld.