Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain With Nausea And Vomiting And Diarrhea. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male with history of binge drinking. He was in his usual state of health prior to his admission to the hospital. He presented with chief complaints of multiple episodes of vomiting, non-bloody, non-bilious, associated with diffuse abdominal pain. The pain was aggravated with drinking alcohol and not associated with any relieving factors. One day prior to the admission to the hospital, he drank heavily, and had acute deterioration of his symptoms of abdominal pain. The pain was diffuse, 7/10 in severity, and non-radiating. He had multiple ED (emergency department) visits in the past with similar complaints aggravated by heaving drinking. 

In the ED (emergency department), the patient was hemodynamically stable and afebrile. His CBC (complete blood count) revealed normal Hb/HCT (hemoglobin/hematocrit), and WBC (white blood count), and slightly low platelet count of 150k (thousand). His CMP (comprehensive metabolic panel) revealed normal lytes, BUN/Cr (blood urea nitrogen/creatinine), and moderately elevated AST/ALT (aspartate aminotransferase/alanine aminotransferase) 322/283, and bilirubin of 2.7. His ethanol levels were undetectable. He had a CT (computed tomography) scan of the abdomen a week before, and it was normal. His Ultrasound abdomen done on this admission was normal. 

The patient was treated with IV (intravenous) fluids, IV (intravenous) multivitamins, thiamine, Pepcid and PPI (proton pump inhibitor). During his hospitalization, his abdominal pain improved and his liver functions were trending down. He was able to tolerate diet, and he was discharged home on Protonix 40mg (milligrams) po (by mouth) daily, and antacids prn (as needed). He was counseled to stop drinking, and he refused to go to alcohol rehab despite repeated counseling. 

No, the Inpatient admission was not medically necessary. 

The patient was admitted with a one-week history of worsening abdominal pain and vomiting aggravated by heavy alcohol abuse. He had multiple ED (emergency department) visits for similar complaints. A week prior, he presented to the ED (emergency department) with similar complaints, and a CT (computed tomography) scan of the abdomen was done and it was normal. 

On this admission, the patient presented again with diffuse abdominal pain, and vomiting aggravated by binge drinking. He has no history of hematemesis, melena. His labs revealed normal Hb/HCT (hemoglobin/hematocrit) and WBC (white blood count), and normal lytes, BUN (blood urea nitrogen) and creatinine. He had moderately elevated liver function tests, which were attributed to alcoholic hepatitis (Mild). During his hospitalization, his symptoms were managed symptomatically with Pepcid and Protonix, he had no recurrence of vomiting, and his abdominal pain improved. He was able to tolerate his diet well, and his liver function tests showed downward trend. He was discharged home on Protonix and antacids and advised to quit drinking and join alcohol rehab. He was advised to follow up with his PCP (primary care provider). Given this clinical scenario, he could have been appropriately and safely managed at a lower level of care without compromising quality of care for the management of his symptoms.