Diagnosis: Acute pancreatitis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The Acute Inpatient Hospitalization was not medically necessary. The care as provided was medically appropriate, but the level at which the care was provided was not medically necessary.

This is a female patient who has a history of being bed-bound. The patient has cholelithiasis, chronic kidney disease, and recurrent pancreatitis. Her last prior admission was earlier that year. The patient presented with epigastric abdominal pain as well as a lipase exceeding 1800.

The patient received intravenous (IV) morphine for pain and supportive care. The patient tolerated an oral diet. The patient had a re-admission within 30 days of two prior hospitalizations for the same condition.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had an infection; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. As such, the care could have been rendered at a lesser level. Indeed, the patient was tolerating an oral intake during this stay.