Digestive System/Gastrointestinal
Inpatient hospital

Diagnosis: Pancreatitis.
Treatment: Inpatient stay.
The insurer denied the inpatient stay.
The health plan's determination is upheld.

The patient is a male with medical history of pancreatitis and former alcohol use. He presented to the emergency department with one month of productive cough, chronic steatorrhea, 6 months of intermittent left-sided abdominal pain, and chronic diarrhea. He noted an unintentional weight loss of 50 pounds over the past 6 months. Vital signs showed tachycardia with pulse rate of 103/minute. Physical examination was notable for lower abdominal tenderness (right more than left), cachexia, and temporal wasting.

The inpatient hospital admission was not medically necessary. The patient had an elevated blood glucose but did not have a diagnosis of diabetic ketoacidosis or hyperosmolar hyperglycemic state. Although imaging was consistent with chronic pancreatitis, as well as sequelae of acute pancreatitis such as pseudocyst, there was no diagnosis of acute pancreatitis. The day after presentation, he had improvement in abdominal pain and was tolerating oral intake. Imaging was suspicious for malignancy of the pancreas and chronic pancreatitis, which required evaluation (and transfer), but did not warrant the acute inpatient level of care. For these reasons, the inpatient level of care is not supported by the provided documentation.