Diagnosis: Chronic Pancreatitis

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

The patient had a history of chronic pancreatitis and pancreatic insufficiency. He had a drainage of a pancreatic pseudocyst. He now presented with vomiting and abdominal pain. He was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. The amylase was 248 (normal to 300). A computed tomography axial (CAT) scan was read as chronic pancreatitis with no change. Intravenous (IV) hydration, proton pump inhibitor therapy (PPI) therapy and pain medications were given.

Milliman care guideline (MCG) guideline M-250 lists indications for admission for Pancreatitis. This patient did not have acute pancreatitis but had chronic pancreatitis. Indications for admission for chronic pancreatitis include evidence of infection, hemodynamic instability, hypoxemia, acute renal failure, and severe electrolyte abnormalities. The patient did not have these conditions.

This patient had chronic pancreatitis. IV hydration, antiemetics, and pain control could have been given with Observation status. He did not meet MCG criteria for admission for Pancreatitis. The health care plan acted reasonably and with sound medical judgement. An inpatient admission was not medically necessary.

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

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