Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Digestive System/Gastrointestinal/Upper stomach pain with nausea and vomiting.
Treatment:  Inpatient Admission.

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

The patient is a male with a medical history of pancreatic cyst, asthma, hypertension, and obesity. He presented to the emergency department with severe epigastric pain radiating to his back, nausea, and vomiting for two days. He had undergone endoscopic ultrasound with fine needle aspiration of the pancreatic cyst. A computed tomography scan of the abdomen and pelvis with oral and intravenous contrast showed acute pancreatitis without definite evidence for necrosis or loculated peripancreatic fluid collection, superimposed hemorrhagic changes cannot be excluded, severe attenuation at the level of the portal-splenic confluence and proximal superior mesenteric vein (which may be secondary to nonocclusive thrombus versus mass-effect from extensive surrounding inflammatory change), stable 2.8 centimeter (cm) previously biopsied cystic lesion within the uncinate process, moderate fat and ascites containing left inguinal hernia extending into the left hemiscrotum, and improving skin thickening and subcutaneous inflammatory change in the left lower quadrant abdominal wall. He was treated with intravenous fluids, Ondansetron, Famotidine, and Ketorolac, as well as a Heparin drip. He was made nil per os. A vascular surgery consultation noted mild abdominal pain and recommended a computed tomography venogram with delayed phase to further evaluate portal system, and anticoagulation per primary team. He had improvement in pain, no nausea or vomiting, and no acute events overnight; he wanted to advance his diet. An ultrasound of the abdomen with Doppler showed hepatic steatosis with patent hepatic vessels; superior mesenteric vein is not seen sonographically. He felt well, had no complaints, was advancing his diet with success, and intravenous fluids were held. Magnetic resonance imaging was recommended as the ultrasound did not visualize the superior mesenteric vein. He had no acute overnight events, remained on a general diet and was tolerating it well, and he denied abdominal pain, diarrhea, and melena. Magnetic resonance imaging of the abdomen showed acute pancreatitis with 4.1 cm acute peripancreatic collection, severe narrowing of the superior mesenteric vein and splenic vein at the confluence, apparent linear hypointensity along the anterior aspect most likely artifactual and unlikely nonocclusive thrombus. 
At issue is the medical necessity for the inpatient admission.

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

No, the inpatient level of care is not supported as medically necessary. The patient had abdominal pain and imaging consistent with acute pancreatitis, and was treated appropriately, with nil per os and intravenous fluids. [1-3] The patient was able to advance his diet quickly. [4,5] Acute pancreatitis is a known complication of endoscopic ultrasound with fine needle aspiration of a pancreatic cyst, but there were no complications, such as pancreatic necrosis pseudocyst on imaging, and superior mesenteric vein thrombus was not found. [6,7] Additionally, there was a lack of hemodynamic instability, organ failure, pleural effusion, or other sequelae to justify acute inpatient level of care, and the treatment provided (including observation, labs, intravenous fluids, imaging, and specialist consultations) could have been provided without the acute inpatient level of care, at an alternate level of care. [1-7] For these reasons, the inpatient level of care is not supported as medically necessary.