Diagnosis: Gastroparesis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

The patient presented with vomiting, diarrhea, and abdominal pain. She was afebrile but had hypertension. The abdominal exam was benign. The white blood cell (WBC) count was 17.6. An abdominal computerized axial tomography (CAT) scan revealed a hiatal hernia and possible gastritis. She had multiple previous admissions for similar symptoms and had a diagnosis of diabetic gastroparesis. A gastric emptying study was done and showed a delay in gastric emptying. She was treated with metoclopramide and pantoprazole. Her diabetes was poorly controlled. The hypertension improved with treatment.

Milliman Care Guideline (MCG) clinical indications for admission for Vomiting (MCG M-370) include having vomiting due to a significant metabolic derangement, hemodynamic instability, severe vomiting not responsive to antiemetic treatment in observation care, severe electrolyte abnormalities, severe pain, bacteremia, acute renal failure, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.

MCG clinical indications for admission for Undiagnosed Abdominal Pain (MCG M-05) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, bacteremia, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions.

This patient had gastroparesis and required intravenous hydration, Reglan, and Pantoprazole. These treatments could have been given with observation status. She did not meet MCG criteria for admission for either Vomiting or Undiagnosed Abdominal Pain.

The health care plan acted reasonably and with sound medical judgment.

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