Diagnosis: Chronic Pancreatitis.
Treatment: Emergent admission.

The insurer denied coverage for emergent admission.

The denial is upheld.

The patient had a history of chronic pancreatitis and a pseudocyst. He presented with abdominal pain, nausea, and vomiting. He was hospitalized about 1 week earlier with similar complaints. He was afebrile and the vital signs were stable. There were no peritoneal signs. The white blood count (WBC) count was 10.9. The lactate was 2.2. The lipase was 34. A computed axial tomography (CAT) scan was read as changes consistent with chronic pancreatitis. The impression of the radiologist was that there was no evidence for acute pancreatitis in this study. Intravenous [IV] hydration and pancreatic enzymes were given.

Clinical indications for admission for Pancreatitis include having acute pancreatitis as manifested by pancreatic enzymes greater than 3 times the upper limit of normal or characteristic findings on imaging studies. In this case, the lipase was normal and the CAT scan was read as chronic pancreatitis and not acute pancreatitis. For chronic pancreatitis, indications for admission include having evidence of infection such as fever or an abscess, hemodynamic instability, hypoxemia, acute renal failure, severe electrolyte abnormalities, or an inability to maintain oral hydration. The patient did not have these conditions.

This patient had chronic pancreatitis. Intravenous (IV) hydration, antiemetics, and pain control could have been given in the emergency room (ER) with observation status. He did not meet MCG [Milliman care guidelines] criteria for admission for Pancreatitis. The healthcare plan acted reasonably and with sound medical judgement. An inpatient admission was not medically necessary.

Based on the above, the medical necessity for the emergent is not substantiated. The insurer's denial is upheld.