Diagnosis: Digestive System/Gastrointestinal/Abdominal Pain.
Treatment: Inpatient Hospital Admission.

The health plan denied the requested inpatient hospital admission as not medically necessary. The health plan's determination is upheld.

The patient is a male with a medical history of diabetes mellitus type 2, alcohol use disorder complicated by prior withdrawal, partial pancreatic resection complicated by chronic pancreatitis, and insomnia. He presented to the emergency department with severe epigastric pain radiating to his back for two days, with the onset after drinking alcohol, and nausea and vomiting. He had been admitted a month ago with similar symptoms. Vital signs were notable for tachycardia with pulse rate of 134/minute. Physical examination was notable for the patient being in acute distress, generalized epigastric abdominal tenderness, and guarding. Labs showed a low white blood cell count of 4.3 , a low platelet count of 119 , and an elevated alanine aminotransferase of 71; the lipase was normal. A computed tomography scan of the abdomen and pelvis showed clear lungs without pneumoperitoneum or visceral distention in the upper abdomen. He was treated with intravenous fluids, Ondansetron, Morphine, and oral Librium. He was placed on a Clinical Institute Withdrawal Assessment (CIWA) protocol. He reported ongoing pain; no withdrawal symptoms were noted. The next day he reported ongoing pain, and he was tolerating a regular diet; no withdrawal symptoms were noted. The patient was discharged with a plan for Primary Care and Gastroenterology follow-up.

At issue is the medical necessity for the inpatient hospital admission.

The health plan's determination of medical necessity is upheld, in whole.

The inpatient level of care is not supported, and the care provided could have been provided at an alternative level of care.

In this case, the patient presented with abdominal pain consistent with acute pancreatitis, although imaging and lipase were unremarkable in the setting of a partial pancreatic resection complicated by chronic pancreatitis. [1-3] He did not have any complications of pancreatitis such as pancreatic necrosis, pseudocyst, or abscess. [4-6] No procedural interventions such as endoscopic ultrasound were necessary. He was appropriately treated with intravenous fluids, and his symptoms improved; his diet was advanced and discharge was then deemed appropriate. He noted alcohol use prior to onset of symptoms, but there was no acute liver failure or alcoholic hepatitis. [7,8] He was monitored for possible alcohol withdrawal, but no protracted or severe acute alcohol withdrawal was documented. [9,10] The interventions performed, including labs, monitoring, imaging, CIWA protocol, and Gastroenterology consultation, could have been performed without the inpatient level of care, at an alternate level of care.