Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient is a teenager with a past medical history of type 1 diabetes that presented to the hospital for assessment of sharp, constant, epigastric abdominal pain, dark red loose stool and diarrhea starting in the last 24 hours. Pain did not radiate and was worse with movement and better with lying down. There was no associated fever, nausea or vomiting. The patient had a good appetite. The patient's initial vitals were notable for Pulse 113, Temperature 100.9 degrees F (Fahrenheit), Blood pressure (BP) 122/84, Respirations 18-20, and room air oxygen saturation of 99%. Admitting laboratories were notable for sodium 135, potassium 3.5, bicarbonate 25, Blood urea nitrogen (BUN) 8, creatinine 0.74, glucose 54, white blood cell 8.1 without a left shift (neutrophils 51.7%, no bands), hemoglobin 14.8, platelets 417, albumin 4.1, C reactive protein (CRP) 106 and lipase 155. A respiratory pathogen panel was negative. Urinalysis was notable for specific gravity 1.018, pH (potential of hydrogen) 6.5 and dip positive for 4+ (plus) glucose and small ketones. Physical exam showed an awake and alert teen in mild discomfort. He had moist mucus membranes and normal capillary refill. Lungs were clear with normal effort. Cardiac exam was unremarkable. The abdomen exam was soft. There was tenderness to palpation in the epigastric area. There was no associated organomegaly, distension, rebound, guarding or masses. Stool for occult blood was negative. An abdominal sonogram was normal. An electrocardiogram (ECG) showed normal sinus rhythm at 91 beats per minute. 
 
This teen appears to have a viral gastroenteritis with mild epigastric discomfort and mild chemical pancreatitis. His clinical presentation (less pain with lying flat) and normal imaging of the visualized pancreas are not consistent with significant clinical pancreatitis. 

In a review of the clinical manifestations and diagnosis of acute pancreatitis also from UpToDate the authors note the following:

The diagnosis of acute pancreatitis should be suspected in a patient with acute onset of a persistent, severe, epigastric pain with tenderness on palpation on physical examination. The diagnosis of acute pancreatitis requires the presence of two of the following three criteria: acute onset of persistent, severe, epigastric pain often radiating to the back, elevation in serum lipase or amylase to three times or greater than the upper limit of normal, and characteristic findings of acute pancreatitis on imaging (contrast-enhanced computed tomography [CT], magnetic resonance imaging [MRI], or transabdominal ultrasonography).

Abdominal ultrasound - In patients with acute pancreatitis, the pancreas appears diffusely enlarged and hypoechoic on abdominal ultrasound. Gallstones may be visualized in the gallbladder or the bile duct. Peripancreatic fluid appears as an anechoic collection on abdominal ultrasound. These collections may demonstrate internal echoes in the setting of pancreatic necrosis.

This patient did not meet the criteria for the diagnosis of acute pancreatitis (no radiation to the back), lipase was not 3 x ULN (3 times the upper limit of normal) and there was normal imaging. As expected with viral gastroenteritis this patient's symptoms quickly resolved without intervention and he tolerated a diet well once permitted to eat. His management of intravenous fluids in the absence of dehydration was not needed and he was merely observed and discharged without symptoms. The adjustment in his insulin regimen did not require the inpatient setting either.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is not substantiated.