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

The patient is a male. He presented with recent nausea and vomiting, for EGD (esophagogastroduodenoscopy). EGD (esophagogastroduodenoscopy) revealed severe esophagitis. He was admitted, hydrated, placed on a clear liquid diet and IV (intravenous) PPIs (proton pump inhibitors) and Zofran. On day two it was noted he tolerated a clear liquid diet and was advanced to a soft diet. On day three he was discharged.

No, the inpatient admission was not medically necessary.

The patient was found to have severe esophagitis on endoscopy. He was tolerating a clear liquid diet after the endoscopy. As there was no evidence of dehydration, electrolyte abnormalities, GI (gastrointestinal) bleeding, intractable vomiting, inability to tolerate oral intake, sepsis or complications after the endoscopy, observation status was medically appropriate. On day two, when he was tolerating a soft diet, he was medically stable for discharge. The proposed acute inpatient hospital stay was not medically necessary.

As acute inpatient admission was not medically necessary, the health plan acted reasonably, with sound medical judgement, and in the best interest of the patient by denying it.