Diagnosis: Vomiting

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld


The patient presented with abdominal pain and vomiting. She has had multiple previous admissions with the same symptoms. The urine toxicology was positive for tetrahydrocannabinol (THC). ln the emergency room (ER) she had a mild tachycardia and an elevated lactate level. At the time of admission she was afebrile, with stable vital signs, and was no longer tachycardic. The abdominal exam was benign. The renal function was normal. The lactate level improved with hydration. The leukocytosis was not as high as on previous admissions and was felt to be reactive. Her symptoms improved with the intravenous (IV) hydration and antiemetics.

Clinical indications for admission for Vomiting (MCG M-370) include having a significant metabolic derangement such as ketoacidosis, hemodynamic instability, 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.

This patient had cyclic vomiting and was using marijuana. She required IV hydration and antiemetics. She improved with this treatment and the lactate level decreased. She could have been given the IV hydration and antiemetics in the ER with observation status. She did not meet Milliman Care Guidelines (MCG) criteria for admission for Vomiting. The denial is upheld

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient hospital stay is not substantiated.