Diagnosis: Digestive System/Gastrointestinal.
Treatment: Inpatient Hospital.
The insurer denied inpatient hospital admission for medical necessity.
The denial was overturned.


This patient is a female with a history of diabetes and hypertension who presented to the hospital with abdominal pain and chest pain for 4 days with nausea, vomiting and diarrhea.
Labs were significant for hyperglycemia, normal electrolytes, and renal function. The computed tomography (CT) scan of the abdomen and pelvis showed a right renal cyst.
The patient was admitted to the hospital for acute gastroenteritis with leukocytosis.
An infectious disease specialist assessed the patient and concluded the patient had abdominal pain due to gastritis, doubtful there was a bacterial infection.
Cardiology was consulted for the chest pain. The cardiac troponin was negative.
The endocrinologist noted, the glycated hemoglobin (hemoglobin A1c) was greater than 10.
The patient was vomiting, had dark stools, and was seen by gastrointestinal(GI) for an endoscopy. The procedure showed Los Angeles (LA) grade C esophagitis, which was biopsied, erosive gastropathy, and bilious gastric fluid, with gastritis. There was erythematous to adenopathy, which was biopsied.
A CT scan of the chest angiogram was done to rule out thromboembolic disease, which was negative. There was evidence of diffuse ground-glass opacities throughout the lungs raising the possibility of edema versus superimposed atypical pneumonia.
The esophagogastroduodenoscopy (EGD) pathology report showed negative H. pylori stain, essentially reflux changes noted in the stomach, and otherwise benign histopathology.
On the day of discharge, the patient was seen by all consultants, with no sign of acute distress.
At issue is the medical necessity of the inpatient level of care.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of inpatient stay is medically necessary for this patient.
This is a complex presentation in a patient experiencing upper GI symptoms and bleed with concurrent diarrhea. The endoscopic evaluation showed a grade C esophagitis and erosive gastropathy with gastritis. There was evidence of leukocytosis, worrisome for an infectious process. There were fluctuations in the renal function, and fluctuations in the blood pressure causing further deterioration of the renal function. There was persistent leukocytosis, which was being assessed daily, and treated with antibiotic therapy.
The patient had persistent nausea and vomiting, with coffee-ground emesis and possible melena, with multiple bouts of diarrhea. The symptoms were severe, as it led to dehydration, with tachycardia, leukocytosis, and trending down hemoglobin. Based on multiple bouts of vomiting, and 7-8 bouts of diarrhea per day during the hospitalization, the patient required Intravenous(IV) fluid support.
Therefore, the inpatient level of care was medically necessary.