Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female. She presented with chief complaints of an approximately one-year history of abdominal pain after eating. The pain was increasing in severity over the prior one week, and there was a two-day history of diarrhea. The abdominal pain did not improve with Prilosec prescribed by her primary care doctor. She presented to the ED (emergency department).

In the ED (emergency department), the patient was hemodynamically stable and afebrile. Her CBC (complete blood count) and Chemistry-panel were unremarkable. The tumor markers including CEA (carcinoembryonic antigen) and CA19-9 (carbohydrate antigen 19-9) were normal. The CT (computed tomography) scan of the abdomen was done which revealed 4 cm (centimeter) x 3.8 cm (centimeter) mass in the body/tail of the pancreas and no lymphadenopathy. The mass was suspicious for pancreatic malignancy. There were also hepatic cysts noted. In addition, she also large pelvic ventral hernia with fat content and no incarceration.

The patient was started on IV (intravenous) fluids, IV (intravenous) Pecid, Zofran, and IV (intravenous) Morphine for pain control. The GI (gastroenterologist) was consulted for endoscopic ultrasound (EUS) and biopsy of the pancreatic mass, but the procedure could not be done

The patient was discharged home with recommendation to have EUS (endoscopic ultrasound) done on an outpatient basis. She was advised to continue taking Prilosec as before.

No, the Inpatient admission was not medically necessary for the management of this patient's condition.

She presented with one year h/o (history of) abdominal pain, post-prandial nature, worse one week prior to her admission the hospital, associated with mild diarrhea. The abdominal pain was not associated with any vomiting, hematemesis, melena, hematochezia. Her symptoms did not get better with prilosec prescribed her PMD (primary physician). On clinical presentation, she was hemodynamically stable and afebrile, Her CBC (complete blood count) was normal, and CMP (comprehensive metabolic panel) did not reveal any electrolyte abnormalities, renal insufficiency, or abnormal liver function tests. Her CT (computed tomography) scan revealed pancreatic mas with no evidence of biliary obstruction and metastatic disease, and large ventral hernia with no evidence of bowel obstruction or incarceration. During her hospitalization, she was able to tolerate diet and her abdominal pain was controlled with IV (intravenous) Morphine given PRN (pro re nata - as needed). The EUS (endoscopic ultrasound) was recommended for the biopsy of the pancreatic mass but the procedure could not be done as  scheduled. She was discharged home to have the EUS (endoscopic ultrasound) done on an outpatient basis. Given this clinical scenario, the acute level inpatient stay was not appropriate and medically necessary and she could have been safely and appropriately managed at the lower level of care.

As per the rationale provided above, the patient remained hemodynamically and afebrile during her stay. She tolerated diet well. She did not have any bowel obstruction or incarceration of the bowel due to large ventral hernia, and the pancreatic mass was not causing any biliary obstruction.