Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal/Stomach Pain. 
Treatment: Inpatient Admission. 

The health plan denied: Inpatient Admission. 
The determination is: Upheld. 

The patient is a female with a history of alcohol abuse, prior necrotizing pancreatitis status/post distal pancreatectomy, and cholecystectomy with splenectomy who was admitted with 2 days of epigastric pain radiating to the back. She felt some relief with food. She has exocrine and endocrine pancreatic insufficiency. She has a history of venous thromboembolism and is on a direct oral anticoagulant. She continues to consume alcohol. She had a pre-syncopal episode prior to admission after bending over with some residual dizziness and ataxia. She endorsed nausea without vomiting. On admission, her vital signs were stable, and she was afebrile. She was tender to palpation in the epigastrium and right upper quadrant (RUQ), without guarding or rebound. Her complete blood count (CBC) was normal except for mild normocytic anemia. She had an elevated venous lactate at 5.1 and a normal lipase. The aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase were all about 3 times the upper limits of normal. Her blood sugar was greater than 400, and her hemoglobin A1C was 13.0. A computed tomography (CT) scan of the abdomen/pelvis with intravenous (IV) contrast showed post-surgical changes, nothing acute. The planned management on admission was largely supportive care. The next day, she was dizzy, with nausea but no vomiting. The following day, she vomited in the afternoon and complained of bloating, which improved with Zofran. Her liver function tests (LFT) were much improved, although the bilirubin was up trending, and magnetic resonance cholangiopancreatography (MRCP) was recommended. A CT scan of the head only showed an old facial fracture. An abdominal x-ray showed a very large stool burden, possibly the cause of her symptoms. 
She was tolerating meals, vomited once, and had less abdominal pain on exam. The total bilirubin was trending back down with the other LFT's. She was tolerating small meals with 1 episode of emesis. She had heartburn and regurgitation on a proton pump inhibitor (PPI), and she started famotidine, as well as Golytely for constipation. The abdominal exam improved, but then she began complaining of pain all over the abdomen; IV Dilaudid was given after missed doses due to IV access coming out. Per the patient, she always has abdominal pain and is never pain-free. Sucralfate was added. She was transitioned to by mouth (PO) Dilaudid, and gabapentin was started for pain control. She was also started on naltrexone to prevent alcohol relapse and was discharged. Of note, during the entire admission, there was a focus on glycemia management with insulin dose titration and coverage for hyperglycemia. 
At issue is the medical necessity of the inpatient admission. 
The health plan's determination of medical necessity is upheld in whole. 
The requested health service/treatment of inpatient admission was not medically necessary for this patient. The patient's level of medical acuity and the care provided did not require an inpatient level of care. The patient has chronic abdominal pain, which is likely multifactorial including post-surgical pain and recurrent pancreatitis in the remnant pancreas. She is still abusing alcohol and appears to have some dependence on opioids. Additionally, she has chronic dyspepsia and heartburn with nausea, bloating, heartburn, and regurgitation. Finally, she appears to have constipation. In the hospital, there were no acute issues beyond these baseline gastrointestinal issues. Her LFT's bumped, perhaps from pre-admission alcohol use, but then quickly normalized. She had no infections, bleeding, or other acute complications of her underlying disease. Her sugars were high on occasion requiring insulin coverage, and she had minor electrolyte abnormalities which were corrected.