Diagnosis: Dehydration

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

This female patient has a history of major depressive disorder, chronic alcohol abuse, chronic pancreatitis, chronic cholecystitis, hypertension, hyperlipidemia, and diabetes mellitus. The patient presented to the Emergency Department (ED) with a 5-day history of not eating due to nausea and a 3-day history of vomiting, with dizziness and low blood pressure (81/55) at home that day, worse with standing up. The patient also reported taking her lisinopril 40 mg that morning. The patient's initial vital signs included: Blood Pressure 75/49, Heart Rate 103, Temperature 97 F, Respiratory Rate 18, and Oxygen Saturation on room air 100%. The patient's electrocardiogram (EKG) showed normal sinus rhythm with no significant ST-T wave abnormalities and QTc of 0.48. The patient's laboratory test results included white blood cell (WBC) count of 6.1, hemoglobin of 14.5, blood urea nitrogen (BUN) of 23, creatinine of 2.08, potassium of 2.8, sodium of 133, chloride of 89, glucose of 237, magnesium of 0.9, alanine aminotransferase of 239, aspartate aminotransferase of 279, lipase of 73, amylase of 38, lactate of 2.0, and troponin of 0.02. The patient's toxicology screen was negative. The patient was treated with intravenous (IV) saline, potassium chloride, magnesium, famotidine, and Reglan. The chart records indicated that the patient felt better after hydration and was ambulating without dizziness. The patient's laboratory test results included creatinine 1.19, potassium 3.0, and magnesium 1.6, and the patient remained hemodynamically stable during her hospitalization. The patient was discharged to home for outpatient management on aspirin, atorvastatin, bupropion, clopidogrel, escitalopram, famotidine, folic acid, ibuprofen, lisinopril, metformin, multiple vitamins, naltrexone, and nicotine patch.

Based on the review of the medical record and literature, inpatient hospital admission was not medically necessary for this patient. There is no clinical evidence that this patient required an acute inpatient level of care to treat her dehydration, which was most likely related to this patient's chronic pancreatitis and alcohol abuse. This level of patient care could have been safely provided and completed in the Emergency Department (ED) or at an observation level of care.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

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