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202306-164413

2023

Metroplus Health Plan

Medicaid

Digestive System/ Gastrointestinal

Inpatient Hospital

Medical necessity

Upheld

Case Summary

Diagnosis: Abdominal pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.


The patient had a history of alcoholic pancreatitis and presented with abdominal pain. He had a recent hospital admission for alcohol withdrawal. He was afebrile and the vital signs were stable. He had abdominal tenderness but did not have peritoneal signs. There was no leukocytosis. The liver and pancreatic enzymes were elevated. The lipase was 194 (normal to 83). He was on pancreatic enzymes for chronic pancreatitis. A computed tomography scan (CT) scan was read as no acute findings and no evidence of pancreatitis. The ethanol level was elevated. He was diagnosed with pancreatitis and alcoholic liver disease. The liver and pancreatic enzymes improved.

Medical necessity was determined based on Milliman Care Guidelines (MCG) M-250 for Pancreatitis. Clinical indications for admission include having acute pancreatitis as manifested by 2 of the following: abdominal pain, serum lipase greater than 3 times the upper limit of normal, and imaging studies indicative of acute pancreatitis. In this case, the pancreatic enzymes were not 3 times above the upper limit of normal and the imaging study was negative for acute pancreatitis. Indications for admission for chronic pancreatitis include inability to maintain oral hydration after observation care, evidence of infection, hemodynamic instability, severe vomiting, stage 3 acute renal failure, altered mental status, and severe electrolyte abnormalities. The patient did not have these conditions.

This patient has liver and pancreatic disease related to alcohol use. He required IV hydration and monitoring of his liver and pancreatic chemistries and Clinical Institute Withdrawal Assessment (CIWA) status. This could have been done with observation status. He did not have evidence of severe pancreatitis and did not have acute liver failure. He did not meet MCG criteria for admission for Pancreatitis.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for inpatient admission is not substantiated.

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