Diagnosis: Abdominal pain and diarrhea.
Treatment: Inpatient admission.

The insurer denied the inpatient admission. The denial is upheld.

The patient is a male, who presented to the emergency department of the facility filing the appeal. The patient reported four days of emesis and watery diarrhea. The patient had generalized abdominal pain. The patient reported his last alcohol consumption was a half-bottle of whisky the night prior. The patient had been unable to eat for the preceding four days. The patient also had a recent trip to India. The patient had a history of hyperlipidemia, alcoholism, hypertension and pancreatitis. The alcohol level was 103. The lipase was mildly elevated at 189. An ultrasound and CT scan showed hepatic steatosis. A stool PCR (polymerase chain reaction) evaluation showed pathogenic E coli species. The patient was admitted for a CIWA (Clinical Institute Withdrawal Assessment) protocol, management of acute pancreatitis, and supportive care including antibiotics. The patient was discharged when deemed stable.

No, the proposed Inpatient admission is not medically necessary.

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 a mild alcohol-induced acute pancreatitis episode and diarrhea from travel; yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for a prolonged 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.