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 male with history of DM (diabetes mellitus), GERD (gastroesophageal reflux disease), and chronic pancreatitis secondary to alcohol abuse. He presented to the hospital with severe abdominal pain of several weeks duration, one day after his discharge from the hospital for acute on chronic pancreatitis.

In the ED (emergency department), the patient was hemodynamically stable and afebrile. He was started on IV (intravenous) fluids, and given multiple doses IV (intravenous) Morphine for pain control, IV (intravenous) Zofran for nausea and vomiting, and IV (intravenous) Protonix. His CBC (complete blood count) revealed normal Hb/HCT (hemoglobin/hematocrit) of 11.8/36.4, and mild leukocytosis, with WBC (white blood count) of 14.8. His CMP (comprehensive metabolic panel) was normal with normal lytes, BUN/Cr (blood urea nitrogen/creatinine), and normal liver function tests, except mildly elevated alkaline phosphatase. His CT (computed tomography) scan of the abdomen revealed mildly distended gall bladder, mildly distended common bile duct, chronic pancreatitis, mild thickening of the wall of the stomach, and fluid-filled distention of the stomach, rule-out partial gastric outlet obstruction.

An MRI (magnetic resonance image) abdomen/MRCP (Magnetic Resonance Cholangiopancreatogram) was done, which revealed changes of chronic pancreatitis, but no evidence of acute pancreatitis, no evidence of acute cholecystitis/cholelithiasis, and mildly biliary prominence/dilation.

The patient was started on regular diet. The GI (gastroenterologist) was consulted, and the patient was made NPO (nothing by mouth) for EGD (esophagogastroduodenoscopy). EGD (esophagogastroduodenoscopy) was done, which revealed deformed pylorus and duodenal bulb, edema of the pylorus and antrum, and two small openings in the antrum suggestive of diverticula/fistula. The UGI (upper gastrointestinal) series with small bowel follow-through was recommended to further evaluate for fistula/diverticula. The dose of Creon for pancreatitis was increased, and the patient was advised to have low fat diet.

The patient left AMA (against medical advice). His discharge medications were Protonix 40 mg (milligrams) po (by mouth) bid (twice daily), Creon 26000 units capsule, 2 capsules TID (three times daily). During his hospital course, he threatened to leave AMA (against medical advice). His dose of pain medication was increased the day before discharge. He was scheduled for barium UGI (upper gastrointestinal series) x-rays, but he eloped from the hospital that day.

No, the Inpatient admission was not medically necessary.

The patient has a history of recurrent abdominal pain due to acute of chronic pancreatitis secondary heavy alcohol abuse, and he had been discharged from the hospital a day before for the same condition. He presented to the hospital again with severe abdominal pain secondary to chronic pancreatitis and gastritis. His CT (computed tomography) scan of the abdomen and MRI/MRCP (magnetic resonance image/ Magnetic Resonance Cholangiopancreatogram) revealed chronic calcific pancreatitis. There was no evidence of acute pancreatitis. The GI (gastroenterologist) evaluated the patient for possible gastritis and gastric outlet obstruction, but EGD (esophagogastroduodenoscopy) did not show any gastric outlet obstruction, and possible gastric diverticula/fistula. The patient, however, was tolerating his diet without any evidence of nausea and vomiting. His pain was in control with Opioid analgesics. He was supposed to have UGI (upper gastrointestinal) series done, but he left AMA (against medical advice). During his hospital stay, he did not reveal any signs of peritonitis or bowel obstruction to warrant surgical intervention, and he did not have any signs or symptoms of GI (gastrointestinal) bleed. Given this clinical scenario, he could have safely and appropriately managed under a lower level of care.