Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nausea and Abdominal Pain
Treatment: Continued inpatient facility admission (180 days)
The insurer denied the inpatient stay (180 days)
The health plan's determination is overturned.

The patient is a female who was initially admitted with an impression of acute edematous pancreatitis. Her pertinent history included recurrent idiopathic pancreatitis, duodenal ulcer, chronic kidney disease, pulmonary embolism (PE) status/post (s/p) inferior vena cava (IVC) filter, hypertension, borderline personality disorder, and bipolar disorder. The treatment plan included intravenous fluids, analgesia, empiric antibiotics, and consultations. The hospital course was complicated by acute respiratory failure requiring intubation, splenic vein thrombosis, malnutrition requiring total parenteral nutrition (TPN), blood loss anemia due to a Mallory Weiss tear, methicillin-susceptible staphylococcus aureus (MSSA) bacteremia secondary to a peripherally inserted central catheter (PICC) line infection, and Coronavirus (COVID-19) pneumonia. 

The inpatient facility admission (180 days) was medically necessary.
Carroll et al. notes the hallmark symptom of acute pancreatitis is the acute onset of persistent upper abdominal pain, usually with nausea and vomiting. The usual locations of the pain are the epigastric and periumbilical regions. The pain may radiate to the back, chest, flanks, and lower abdomen. Patients are usually restless and bend forward (the knee-chest position) in an effort to relieve the pain because the supine position may exacerbate the intensity of symptoms. Physical examination findings are variable but may include fever, hypotension, severe abdominal tenderness, guarding, respiratory distress, and abdominal distention.[1]

Colgan et al. listed criteria for the diagnosis of pyelonephritis. This includes a history of urinary frequency, dysuria, flank pain, fever, chills, nausea, and/or vomiting. Concerning physical examination findings include a temperature greater than 100.4 degrees Fahrenheit (F), tachycardia, costovertebral tenderness and suprapubic tenderness. Concerning laboratory findings include leukocytosis and a urinalysis showing positive leukocyte esterase test, microscopic pyuria or hematuria, or white blood cells casts. Furthermore, indications for hospitalization include comorbid conditions (e.g., renal dysfunction, urologic disorders, diabetes mellitus, or advanced liver or cardiac disease), hemodynamic instability, male sex, metabolic derangement (e.g., acidosis), pregnancy, severe flank or abdominal pain, inadequate oral intake, and/or very high fever (greater than (>[greater than])103F).[2]

The patient was initially admitted with an impression of acute edematous pancreatitis. The hospital course was complicated by acute respiratory failure requiring intubation, splenic vein thrombosis, malnutrition requiring TPN, blood loss anemia due to Mallory-Weiss tear, MSSA bacteremia secondary to PICC line infection, and COVID-19 pneumonia.
Clinical indications for an extended inpatient level of care were met. The hospital course continued to be complex and complicated with the development of pyelonephritis with a renal abscess and C. diff colitis on. There was a concern for Heparin induced thrombocytopenia on and recurrent pancreatitis requiring intravenous analgesia throughout the time frame. Treatment included multiple, separate antibiotic courses, intravenous fluids, surveillance imaging, therapy services, wound care, and consultations.[3]