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202304-161147

2023

Healthfirst Inc.

Essential Plan

Digestive System/ Gastrointestinal

Inpatient Hospital

Medical necessity

Upheld

Case Summary

Diagnosis: Abdominal/Stomach Pain
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient hospital stay.
The determination is upheld.

The patient is a male with a medical history of alcohol abuse, pancreatitis, diabetes mellitus, and hypertension. He presented to the emergency department with epigastric abdominal pain for two days, nausea, vomiting, and loose bowel movements. He had restarted alcohol use 2 days prior. His vital signs were notable for an elevated blood pressure of 149/91 millimeters of mercury (mmHg) and tachycardia with heart rate of 132 beats per minute. The physical examination was notable for right sided and epigastric abdominal tenderness, tongue fasciculation, and tremor. The labs showed an elevated creatinine of 2.6, an elevated glucose of 332, an elevated aspartate aminotransferase of 228, an elevated alanine aminotransferase of 404, and a normal lipase. His urine drug screen was positive for cocaine and opiates. A chest x-ray showed no acute cardiopulmonary process. A computed tomography (CT) scan of the chest, abdomen, and pelvis with angiogram showed no aneurysm or dissection, no pulmonary embolism, no clear explanation for chest pain or right-sided back pain, hepatic steatosis, and prior splenectomy and distal pancreatectomy, with residual fluid collection adjacent to the pancreatic stump with unchanged appearance. He was treated with intravenous Ativan, morphine, morphine sulfate, Zofran, pantoprazole, amlodipine, thiamine, folate, fluids, and oral sucralfate and Maalox. He was placed on a Clinical Institute Withdrawal Assessment (CIWA) protocol. He left against medical advice, with a plan for Primary Care follow-up.

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

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

The requested health service/treatment of inpatient hospital admission is not medically necessary for this patient. In this case, the patient presented with abdominal pain, nausea, vomiting, and diarrhea in the setting of alcohol intake [1-3]. He did not meet criteria for pancreatitis, and there were no complications 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. His liver enzymes were elevated, but there was no acute liver failure or alcoholic hepatitis [7, 8]. He was monitored for alcohol withdrawal, but no complications of alcohol withdrawal such as seizure were documented [9, 10]. The interventions performed during his short stay, including labs, monitoring, imaging, and alcohol withdrawal protocol, could have been performed without the inpatient level of care.

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