Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department with abdominal pain, nausea, vomiting, and diarrhea for two months, worse in the past few days and she had hematochezia. She had been seen previously in the emergency department with the same symptoms. Her lipase had been elevated and rising. An ultrasound had shown gallbladder sludge and a positive Murphy sign, but no gallbladder wall thickening or pericholecystic fluid; another ultrasound had shown gallbladder sludge. She had attempted Zofran, Pepcid, and Carafate without significant improvement.
Her vital signs were notable for a fever with a temperature of 100.8 degrees Fahrenheit. The physical examination was notable for a soft abdomen with moderate right upper quadrant and epigastric abdominal tenderness. Lab results showed an unremarkable blood count and comprehensive metabolic panel, and elevated lipase of 555 units per liter (U/L) (upper limit of normal 393 U/L). She was treated with intravenous fluids, Pepcid, Zofran, Zosyn, oral Tylenol, and subcutaneous Lovenox.
Cholecystitis, pancreatitis, and hepatic abscess were considered. A gastroenterology consultation concluded that she had possible cyclic vomiting secondary to marijuana use, and recommended magnetic resonance cholangiopancreatography, monitoring lipase, Pepcid, Zofran, regular diet as tolerated, and Gastroenterology work-up as an outpatient. The next day she had pain requiring intravenous morphine. Lab results showed an unremarkable complete blood count, low potassium of 3.2 millimoles per liter (mmol/L), and elevated lipase of 570 U/L. A hepatobiliary iminodiacetic acid (HIDA) scan was normal. She was treated with oral potassium chloride. 
Magnetic resonance imaging of the abdomen with a magnetic resonance cholangiopancreatography was unremarkable. An esophagogastroduodenoscopy showed normal esophagus, mild gastritis, and normal duodenum. She was discharged on pantoprazole and dicyclomine. At issue is the medical necessity for an inpatient level of care.
The inpatient stay was not medically necessary for this patient. The patient had abdominal pain and nausea consistent with acute pancreatitis with documented symptoms, but no documented elevated lipase greater than three times the upper limit of normal or imaging consistent with pancreatitis [1-4]. Other possibilities to explain her symptoms included inflammation (esophagitis, gastritis, duodenitis, peptic ulcer disease), although these symptoms improved within two days, and endoscopy showed mild gastritis but no ulcer or active gastrointestinal bleeding [5,6]. Cholecystitis was suspected but not documented; also, there was no imaging evidence of biliary obstruction, biliary or pancreatic mass, bile leak, ascending cholangitis, hepatic abscess, or other complications which would require the inpatient level of care [7-9]. The care provided, including imaging, proton pump inhibitor therapy, esophagogastroduodenoscopy, and specialist consultations, could have been performed without the inpatient level of care, at a lower level of care. For these reasons, the inpatient level of care is not supported as medically necessary.