Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute pancreatitis
Treatment: Inpatient Hospital
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld.

This is a case of a male admitted for a diagnosis of acute pancreatitis. The patient presented with stomach pain for a week prior to admission. In the emergency room, he was found to have evidence of acute pancreatitis both on labs and computed tomography (CT) imaging. Vital signs demonstrated a temperature of 97.5F., a pulse of 90 beats per minute (bpm), a respiratory rate of 17/minute, and a blood pressure of 144/88 mmHg (millimeters of mercury). Physical exam showed no acute distress or altered mental status. Bowel sounds were normal and there was no distention or masses. His abdomen was soft. There was mild epigastric tenderness. The creatinine was 1.0 with a glucose of 204. The white blood cell count was 18.1. A computed tomography (CT) of the abdomen showed moderate pancreatitis. A magnetic resonance cholangiopancreatography (MRCP) was performed which confirmed pancreatitis with small caliber intrahepatic and extrahepatic ducts. The common bile duct was normal caliber. He was recommended to be treated with fluid resuscitation, pain control and a clear liquid diet. Diet was able to be advanced eventually to soft foods and at the time of discharge he was tolerating a regular diet. He was able to be discharged.
At issue is the medical necessity for the inpatient stay.

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

No, the medical necessity of the admission has not been established.
According to Up-to-date, 2021:
"According to the severity, acute pancreatitis is divided into the following:
Mild acute pancreatitis which is characterized by the absence of organ failure and local or systemic complications.
Moderately severe acute pancreatitis which is characterized by transient organ failure (resolves within 48 hours) and/or local or systemic complications without persistent organ failure (>48 hours).
Severe acute pancreatitis which is characterized by persistent organ failure that may involve one or multiple organs."
The patient in this case would be classified as having mild acute pancreatitis, given the absence of organ failure or local/systemic complications. There was no stone identified on advanced imaging. The aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were normal. Lactic acid was normal range. The hematocrit and blood urea nitrogen (BUN) were normal. Renal function was normal. There was no hemodynamic instability or fever, altered mental status, tachycardia, or tachypnea. There was no surgical intervention required such as an endoscopic retrograde cholangiopancreatography (ERCP). There was no pleural effusion or pulmonary infiltrate on chest x-ray. The patient was treated with standard interventions with fluid resuscitation and pain control. His diet was able to be advanced reasonably soon, which all could have happened under an alternate level of care.
Although the patient required services in the hospital setting the monitoring, diagnostics testing, and therapeutic interventions prescribed could have been rendered at an alternate level of care. Therefore, the medical necessity of the admission has not been established.