Diagnosis: Vomiting

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is upheld

The patient is a pregnant female who presented to the emergency room with persistent vomiting for two days. Her electrolytes were normal. Urinalysis showed trace ketones. The patient was admitted and received intravenous (IV) fluids and vitamins, Zofran 4 milligrams (milligrams) IV every 8 hours, Prochlorperazine IV every 8 hours and Vitamin B 6 IV every 8 hours. she was discharged after tolerating a oral diet.

As per ACOG (American College of Obstetricians and Gynecologists), there are no controlled trials comparing hospitalization with outpatient management of hyperemesis gravidarum. When a woman cannot tolerate liquids without vomiting and has not responded to outpatient management, hospitalization for evaluation and treatment is recommended. After the patient has been hospitalized on one occasion and a workup for other causes of severe vomiting has been undertaken, intravenous hydration, nutritional support, and modification of antiemetic therapy often can be accomplished at home. Nevertheless, the option of hospitalization for observation and further assessment should be preserved for patients who experience a change in vital signs or a change in affect or who continue to lose weight.

According to UpToDate: Women who are unable to maintain adequate hydration, normal electrolyte levels, and acid-base balance with the initial interventions described above should be admitted to the hospital for intravenous fluids and medications. Women who have severe vomiting, weight loss, ketonuria, dry mucous membranes, poor skin turgor, dehydration, hypotension, alkalosis from hydrochloric acid loss, hypokalemia, or nutritional deficiencies are admitted to the hospital. The decision to admit versus discharge to home needs to be individualized based on the patient's severity of disease, resources, ability to comply with the management plan, and ability to obtain and have access to outpatient resources.

This patient did not have hyperemesis gravidarum. There is no report of weight loss, her electrolytes were normal. She had trace ketones only. She had some vomiting of pregnancy and needed hydration. IV hydration does not require hospital admission.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The inpatient admission is not considered medically necessary for this patient.

The insurer's denial of coverage for inpatient hospital admission is upheld. Medical Necessity is not substantiated.