Diagnosis: Pancreatitis

Treatment: Inpatient hospital admission

The insurer denied coverage for an inpatient hospital admission.

The denial is overturned.

The patient had a history of pancreatitis and presented with upper abdominal pain and vomiting. He was afebrile and the vital signs were stable. Upper abdominal tenderness was present, but there was no rebound or guarding. He was diagnosed with pancreatitis. It was felt that this could be medication related and enalapril and chlorthalidone were held. The lipase was 842 (normal to 78). An ultrasound revealed a normal pancreas.

Clinical indications for admission for Pancreatitis [MCG (Milliman Care Guidelines) M-250] include having acute pancreatitis as manifested by 2 of the following indications. These include abdominal pain, serum lipase greater than 3 times the upper limit of normal, and imaging studies indicative of acute pancreatitis. In this case, the patient had upper abdominal pain and a lipase level that was much greater than 3 times the upper limit of normal.

This patient had acute pancreatitis of unknown etiology. It was felt to possibly be medication induced. He met the MCG criteria for a hospital admission. Therefore, the health care plan did not act reasonably or with sound medical judgment. An inpatient hospital admission was medically necessary. The denial is overturned.

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical necessity is substantiated.