202206-150824
2022
Metroplus Health Plan
HMO
Digestive System/ Gastrointestinal
Inpatient Hospital
Medical necessity
Upheld
Case Summary
Diagnosis: Pancreatitis
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld.
The patient is a male with a history of (H/O) alcohol abuse admitted for acute pancreatitis. Imaging earlier in the month demonstrated a pancreatic cyst. The computed tomography (CT) scan from the day before the admission showed acute edematous pancreatitis and possibly developing small pseudocysts. He was admitted the day prior but left against medical advice (AMA) then returned to the hospital for pain management. The patient smokes cigarettes and marijuana and uses a lot of ibuprofen. He is able to tolerate by mouth (PO) and is not having nausea or vomiting. On exam, he is afebrile and not in acute distress. On exam, he is tender in the epigastric region without guarding or rebound. On admission, the patient was started on narcotics for pain relief. He was given lactated ringers. Clinical Institute Withdrawal Assessment (CIWA) = 0.
The inpatient hospital admission was not medically necessary. A lower level of care was appropriate. The Inpatient care was not required as the patient's computed tomography (CT) showed no concerning pancreatic findings such as necrosis or a large fluid collection. The patient did not have severe systemic complications from pancreatitis such as adult respiratory distress syndrome (ARDS). Additionally, the patient was able to take PO without nausea or vomiting. Observation with parenteral narcotics and aggressive intravenous (IV) hydration was appropriate.