Diagnosis: Grade D (one or more mucosal break involving 75% [percent] of the esophageal circumference) esophagitis and gastritis

Treatment: Inpatient Level of Care

The insurer denied coverage for inpatient level of care

The denial is upheld

The patient had a history of pancreatitis and presented with abdominal pain, nausea, and vomiting. He was afebrile but had hypertension. The abdominal exam was benign. The lipase was 171. An abdominal computed axial tomography (CAT) scan was normal. Intravenous (IV) hydration and proton pump inhibitor (PPI) therapy were given. An endoscopy revealed grade D (one or more mucosal break involving 75% [percent] of the esophageal) esophagitis and gastritis.

Clinical indications for admission for Undiagnosed Abdominal Pain (Milliman Care Guidelines [MCG]) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, bacteremia, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions.

Clinical indications for admission for Esophageal Disease (MCG) include esophageal perforation, complete obstruction, mediastinitis, severe vomiting that is not responsive to antiemetics, severe electrolyte abnormalities, severe pain that is not responsive to analgesia, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.

This patient had abdominal pain and vomiting and was diagnosed with grade D esophagitis and gastritis. IV hydration, antiemetics, and PPI therapy could have been given in the emergency room (ER) with observation status. He was stable to have had the endoscopy performed on an ambulatory basis. He did not have CAT scan findings or abdominal exam findings that were consistent with acute pancreatitis. He did not meet MCG criteria for admission for either Undiagnosed Abdominal Pain or Esophageal Disease.

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 level of is upheld. Medical Necessity is not substantiated.