Appeal type: Medical necessity
Decision: Upheld

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

This is a patient with abdominal pain. His temperature was normal, blood pressure (BP) was 140/78, and oxygen saturation was 100%. He was status post an abdominal procedure 3 days prior. He had a biopsy of the pancreatic mass by endoscopic procedure. He was alert, oriented, and had a past medical history of hypertension. His home medications included hydrochlorothiazide and metoprolol. The abdomen was tender in the right lower quadrant, with no vomiting and no distress. There was no gastrointestinal (GI) bleeding. He was given fluids. There was a slight elevation of his amylase 154 (upper limits of normal 110), renal function was normal, potassium 3.2, white blood cell count (WBC) 12.9, hemoglobin 13.4, platelets normal, liver tests normal, lactic acid normal, and prothrombin time normal. A chest x-ray was normal, and an abdominal x-ray showed no obstruction or free air. He stated his pain began after the endoscopic ultrasound with fine needle aspiration of the pancreatic mass. Tylenol did not relieve the pain. There was no high fever. The impression was mild pancreatitis post a pancreas mass biopsy. A computed tomography (CT) scan of the abdomen showed a 4 centimeter (cm) pancreatic mass and an 11.5 cm right kidney mass consistent with renal cell carcinoma. There was no acute inflammatory condition, no ascites, no evidence of pancreatitis, no diverticulitis. Over the next 24 hours he responded to intravenous (IV) fluid and pain management. He was able to tolerate his diet. He was discharged feeling better the next day. He was given Tramadol for pain and his temperature remained normal. The repeat lipase was normal.
At issue is the medical necessity of an inpatient stay.

This patient did not require acute hospital level of care. He presented with pain after an endoscopic ultrasound with fine needle aspiration three days prior. Although there was a slight elevation of pancreatic enzymes, the CT scan showed no ascites, no bowel obstruction, and no evidence of an acute pancreatitis. The same pancreatic and renal mass that were known prior to the admission were observed on the CT scan. There was no GI bleeding, no high fever, no hemodynamic instability. He improved rapidly in less than 24 hours, was able to tolerate a diet, had a repeat normal lipase level, and went home. There was no active comorbid condition, no cardiopulmonary or renal problem, only a mild decrease in potassium, normal renal function, and no requirement for acute care to give fluids, treat with analgesics, observed for 24 hours and discharged. Therefore, an acute hospital level of care was not medically necessary.
Garber described: "Complications arising from acute pancreatitis follow a progression from pancreatic/peripancreatic fluid collections to pseudocysts and from pancreatic/peripancreatic necrosis to walled-off necrosis that typically occur over the course of a 4-week interval. Treatment relies heavily on fluid resuscitation and nutrition with advanced endoscopic techniques and cholecystectomy utilized in the setting of gallstone pancreatitis. When necessity dictates a drainage procedure (persistent abdominal pain, gastric or duodenal outlet obstruction, biliary obstruction, and infection), an endoscopic ultrasound with advanced endoscopic techniques and technology rather than surgical intervention is increasingly being utilized to manage symptomatic pseudocysts and walled-off pancreatic necrosis by performing a cystogastrostomy." After the slight elevated pancreatic enzymes normalized there were no complications requiring acute care.
Shah described: "The last two decades have seen the emergence of significant evidence that has altered certain aspects of the management of acute pancreatitis. While most cases of acute pancreatitis are mild, the challenge remains in managing the severe cases and the complications associated with acute pancreatitis. Gallstones are still the most common cause with epidemiological trends indicating a rising incidence. The surgical management of acute gallstone pancreatitis has evolved."
There were no complications requiring acute care; there was no pancreatitis, no bleeding, no infection, and no vomiting.
Waller described: "Pancreatitis is an inflammatory process within the pancreas. While the disease is often mild, severe forms can have a mortality rate of up to 30%. The diagnosis of pancreatitis requires two of the following three criteria: epigastric abdominal pain, an elevated lipase, and imaging findings of pancreatic inflammation. The most common etiologies include gallbladder disease and alcohol use. After the diagnosis has been made, it is important to identify underlying etiologies requiring specific intervention, as well as obtain a right upper quadrant ultrasound. The initial management of choice is fluid resuscitation and pain control. Recent data have suggested that more cautious fluid resuscitation in the first 24 hours might be more appropriate for some patients. Intravenous opiates are generally safe if used judiciously. Appropriate disposition is a multifactorial decision, which can be facilitated by using Ranson criteria or the Bedside Index of Severity in Acute Pancreatitis score. Complications, though rare, can be severe." No complications of pancreatitis, no imaging consistent with pancreatitis, was documented in this case that would require acute care.