Diagnosis: Nausea, vomiting, and abdominal pain
Treatment: Inpatient emergency admission
The insurer denied coverage for inpatient emergency admission
The denial is upheld

The patient had a history of morbid obesity and had a sleeve gastrectomy. She required a readmission after the procedure for nausea and vomiting. She again returned to the Emergency Room (ER) about a month later with similar symptoms. She now presents with nausea, vomiting, and abdominal pain. She was afebrile and the vital signs were stable. The abdominal exam was benign. An abdominal computed axial tomography (CAT) scan showed no complications from the surgery. There was no evidence of bowel obstruction. The potassium was 2.7. Intravenous (IV) hydration with potassium replacement was given. She was given a Bariatric diet and was able to tolerate it.

Milliman Care Guideline (MCG) Clinical indications for admission for Dehydration (MCG M-123) include hemodynamic instability, acute renal failure, altered mental status, inability to maintain oral hydration after observation care, and severe electrolyte abnormalities. The electrolyte abnormality may be a potassium less than 2.5 that is not corrected to near baseline after observation care or a potassium less than 3 with cardiac findings. The patient did not have these conditions.

Clinical indications for admission for Vomiting (MCG M-370) include having a severe metabolic derangement, hemodynamic instability, acute renal failure, or severe electrolyte abnormality such as a potassium under 2.5 or a sodium less than 130 that does not correct to near baseline despite observation treatment. The patient did not have these conditions. Her electrolytes improved with treatment.

This patient had vomiting resulting in electrolyte abnormalities. However, both the hypokalemia and hyponatremia were able to be corrected. IV hydration and antiemetics could have been given with observation care. She did not have acute renal failure. She required dietary changes to a Bariatric diet, but this could also have been done with observation status. She did not meet MCG criteria for acute care for either Dehydration or Vomiting.

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

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