Diagnosis: Nausea and Vomiting
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female teen with complicated past medical history including oppositional defiant disorder, victim of sex trafficking, adjustment disorder, learning disability, conduct disorder, and anemia that presented to the emergency department for the third time with three-day history of constant lower abdominal pain and several episodes of vomiting daily. The pain improved with emergency department treatments but returned the following day. She was notified earlier in the day of positive Chlamydia testing and was on treatment. She has a history of constipation but had positive response to laxative earlier in the day. She reported smoking marijuana every couple days (last smoked at the onset of symptoms).

The patient's vital signs included temperature 36.9, heart rate 91, respiratory rate 22, and blood pressure 127/81. Examination was significant for moderate distress, rocking in the bed, tearful, non-toxic appearance, moist mucous membranes, regular heart rate and rhythm, normal bowel sounds with no distention, abdominal tenderness in the bilateral lower quadrants and suprapubic region, no costovertebral angle (CVA) tenderness, no guarding or rebound, and non-focal neurologic exam. The differential diagnosis included ovarian torsion versus pelvic inflammatory disease (PID) / tubo-ovarian abscess versus cannabinoid hyperemesis versus appendicitis. Laboratory evaluation was reassuring. Computed tomography (CT) of the abdomen was overall unremarkable with no evidence of appendicitis. Transvaginal ultrasound was also negative with only a small amount of pelvic fluid. Gynecology was consulted with recommendations to complete full evaluation for sexually transmitted infections but did not feel that pelvic infection was likely. She was treated with intravenous fluids, Tylenol, Zofran, 1000 milligrams of azithromycin (for Chlamydia), and Toradol. Toradol was ineffective, so she was treated with Haldol for suspected cannabinoid hyperemesis.

Because of persistent pain and inability to tolerate anything by mouth, the patient was admitted for further management. She did well with no further abdominal pain, no nausea or vomiting, no fevers. She was able to tolerate her diet and she received no medications for pain or nausea. She was subsequently deemed stable for discharge home.

Coverage for acute inpatient admission is being requested as being medically necessary. The health plan denied acute inpatient admission and approved the hospital stay at observation level of care.

No, acute inpatient admission was not medically necessary.
Cannabis hyperemesis syndrome has recently become part of the differential diagnosis for patients that present with recurrent vomiting in conjunction with chronic cannabis use. This syndrome is characterized by periodic nausea, vomiting, and abdominal pain. These patients also report frequent and compulsive bathing in hot water because it provides some temporary relief. In between episodes, patients are usually completely asymptomatic. The mechanism is not fully understood, because cannabis has been used as an anti-emetic agent in some populations but may involve decreased gut motility and gastric emptying and overstimulation of the cannabinoid receptor type-one in the intestine. There is some thought that it may be a subtype of cyclic vomiting syndrome. Rome IV criteria for diagnosis include the following: symptoms present for past three months with onset at least six months prior, stereotypical episodes lasting less than a week, at least three episodes in the last year with two episodes in the last six months, and no vomiting in between episodes. Management involves symptomatic treatment, ruling out other causes of recurrent vomiting and abdominal pain. The differential diagnosis includes cyclic vomiting, a syndrome for which cannabis is considered a potential treatment, further complicating this issue.

This female teen with complex social and psychological history presented to the emergency department for the third time with persistent lower abdominal pain and nausea/vomiting. She was unable to tolerate anything by mouth in the emergency department. She received only partial benefit from Tylenol, Toradol, and Haldol. Because she chronically used marijuana, cannabinoid hyperemesis was high on the differential list even though this was her first episode. Pelvic inflammatory disease was considered because of her high-risk sexual behaviors and recently diagnosed Chlamydia infection, but she had no clinical or radiographic evidence. While it was reasonable and appropriate to continue to monitor her for resolution of pain and ability to tolerate fluids by mouth, she was overall hemodynamically stable without significant dehydration and no evidence of impending circulatory collapse. She did not require acute inpatient admission and could have been safely managed at lower level of care such as observation.