Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcoholic Pancreatitis.
Treatment: Inpatient Hospital Stay.
The insure denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a medical history of alcoholic pancreatitis, active ongoing alcohol use, gastroesophageal reflux disease (GERD), and esophageal varices. He presented to the emergency department with shakes, severe abdominal pain, nausea, vomiting, inability to tolerate a diet, and diarrhea with bleeding. Vital signs were notable for elevated blood pressure of 145/94 millimeters of mercury (mmHg). The physical examination was notable for diffuse mild abdominal tenderness. Lab results showed low potassium of 3.2 millimoles per liter (mmol/L), elevated lactate of 3.7 mmol/L, elevated bilirubin of 1.4 milligrams per deciliter (mg/dL), and elevated ethanol of 127.9 mg/dL.
A computed tomography scan of the abdomen and pelvis showed cecitis/pancolitis favoring infectious or inflammatory etiology, ill-defined uncinate process of the pancreas, hypoattenuation/possible nodule with calcification, shotty subcentimeter nonspecific lymph nodes, and mild mesenteric fatty attenuation which may reflect panniculitis. He was treated with intravenous ciprofloxacin and metronidazole, lorazepam, and normal saline bolus. He was made nil per os. He was placed on a Clinical Institute Withdrawal Assessment (CIWA) protocol. A gastroenterology consultation concluded that he had pancolitis and a pancreatic lesion; the recommendation was to stop alcohol use, vigorous rehydration, empiric treatment for colitis, elective endoscopy and colonoscopy, and further evaluation of uncinate process lesion with magnetic resonance imaging. He had persistent abdominal pain, and remained on intravenous fluids while nil per os (NPO). Lab results showed a low hemoglobin of 12.0 g/dL and hematocrit of 34.7%, low potassium of 3.1 mmol/L, and elevated bilirubin of 1.7 mg/dL. He felt better and wanted to try solid food. He denied abdominal pain, nausea, and vomiting, and was tolerating oral feeding. He was feeling better and tolerating solid food, and denied abdominal pain. He was discharged on ciprofloxacin and metronidazole (with a probiotic), with a plan for Primary Care and Gastroenterology follow-up. At issue is the medical necessity of the inpatient level of care.

The inpatient level of care is not medically necessary. The patient had abdominal pain, nausea, vomiting, and diarrhea consistent with gastroenteritis or colitis, and colitis was found on imaging; however, he was not found to have complications such as toxic megacolon, bowel perforation, or bowel obstruction. The standard of care for the evaluation of and treatment of colitis was appropriately performed, including intravenous fluids and empiric antibiotic therapy [1-3]. No other colitis-related complications, such as inflammatory bowel disease flare, peritonitis, toxic megacolon, sepsis, abscess, or other complication was documented [4-7]. The patient's symptoms were also consistent with inflammation (esophagitis, gastritis, duodenitis, peptic ulcer disease) or alcohol-induced gastritis; however, there was no sustained tachycardia or hypotension, gastrointestinal bleeding, or gastrointestinal perforation, and endoscopy while in hospital was not deemed necessary [8,9]. He did not meet criteria for the diagnosis of pancreatitis [10,11]. The patient did not have any signs of protracted alcohol withdrawal, and he was appropriately maintained on a CIWA protocol [12,13]. All of the measures that were undertaken, such as observation, monitoring, labs, gastroenterology consultation, and empiric antibiotic therapy, could have been performed without the acute inpatient level of care, at a lower level of care.