Diagnosis: Gastroenteritis and Dehydration.
Treatment: Inpatient Admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient had a history of liver cancer and presented with vomiting and diarrhea. The diarrhea was not bloody. In the emergency room the blood pressure was 74/49. By the time of admission, the blood pressure was 124/81. The abdominal exam was benign. A computed tomography (CT) scan revealed liver cancer and diverticulosis. The creatinine was initially 1.61 on repeat came down to normal the following day. He received intravenous hydration and his symptoms improved. He was able to tolerate a diet.

Clinical indications for admission for Gastroenteritis (M-170) include having a suspected severe infection such as bloody diarrhea, severe abdominal pain, acute renal failure as defined by a 3-fold rise in the serum creatinine severe electrolyte disorders and an inability to maintain oral hydration after observation care. The patient did not have these conditions. Hemodynamic instability is also an indication for admission if the hypotension persists despite appropriate treatment. In this care, the hypotension resolved with intravenous hydration.

This patient had a gastroenteritis and dehydration. Intravenous hydration was required. The blood pressure and renal function then improved. The intravenous hydration could have been given with observation status. He did not meet Milliman Care Guidelines (MCG) criteria for admission for gastroenteritis. The healthcare plan acted reasonably and with sound medical judgement. An inpatient hospitalization was not medically necessary.

The insurer's denial of coverage for inpatient hospitalization is upheld. Medical necessity is not substantiated.