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 has a past medical history significant for hypertension, diabetes mellitus, and chronic kidney disease who presented to the hospital with complaints of abdominal pain and nausea. The review of systems was negative for a fever, chills, abdominal pain, diarrhea, chest pain, shortness of breath, dysuria, or any other complaints. The patient stated that his last use of alcohol was about a week before the presentation, but that he smoked marijuana the day before his presentation.
At the time of the initial evaluation, the patient was afebrile. The pulse rate was 84 beats per minute (bpm), respiratory rate 18 breaths/minute, blood pressure 194/94, oxygen saturation 98% on room air. The patient was in no acute distress. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. The rest of the physical exam was unremarkable.
Laboratory evaluation revealed that the serum sodium was 137, potassium 4.0, chloride 106, bicarbonate (HCO3) 15, blood urea nitrogen (BUN) 24, creatinine 1.68, and glucose 233. The lipase was 129 and the creatine phosphokinase (CPK) was 367. The troponin was normal. The white blood cell count was 11.8, hemoglobin 11.7, hematocrit 33.7, and platelets 262.
The patient was admitted to the hospital with a diagnosis of abdominal pain, nausea, vomiting, and resolving pancreatitis. At the same time, it was noted in the history and physical (H&P) note that the computed tomography (CT) scan of the abdomen was negative for acute pancreatitis. Other clinical problems mentioned at the time of admission included uncontrolled blood pressure, chronic kidney disease, anemia, microscopic hematuria, diabetes mellitus, vitamin D deficiency, and depression.
During the hospital stay, the patient's clinical condition improved. According to the progress note, his abdominal pain improved on the next day after the day of admission and the patient continued to tolerate his diet. Since the patient's clinical condition continued to improve, he was discharged from the hospital.
At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary at the acute inpatient level of care.
There was no strong evidence that the patient had pancreatitis. The diagnosis of acute pancreatitis is established by the presence of at least 2 of the following:
-Abdominal pain consistent with the disease
-Serum amylase and/or lipase greater than (>) 3 times the upper limit of normal
-Characteristic findings on contrast-enhanced cross-sectional imaging studies
In this particular case, the patient had a lipase of 129, which was only two times higher than the reference range. The patient had no radiographic evidence of acute pancreatitis based on the CT scan of the abdomen. The patient's symptoms improved relatively quickly. At the time of admission, the patient was already able to tolerate some food. The admitting physician stated in the H&P note that the patient tolerated a half portion of rice and chicken.
It is difficult to say if the patient had acute pancreatitis during his most recent admission, which occurred just days before this admission. However, on the next day after the day of the current admission, there was reported improvement in abdominal pain, nausea, and diarrhea.
The review of the medical records clearly demonstrated that the patient's symptoms did not result in severe dehydration or significant electrolyte abnormalities. At the time of admission, the patient had an elevated creatinine level, however, it was most likely consistent with his previously diagnosed chronic kidney disease. There was no evidence that the patient's creatinine rose by 0.3 milligrams per deciliter (mg/dl) within 48 hours before the day of admission. The rise of creatinine greater or equal to 0.3 mg/dl within 48 hours is one of the diagnostic criteria of acute kidney injury that can be applied to this clinical case. According to the records, one day before the day of current admission the patient's creatinine was 1.47, and on the day of admission, it was 1.68. (less than 0.3mg/dl). There was no evidence that the patient had severe pain requiring admission at the acute inpatient level of care.
Taking into consideration all of the information, neither the severity of the patient's condition nor the complexity of the services provided rose to the acute inpatient level of care. There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care with subsequent transition to outpatient care, rather than admission to an inpatient level of care.
Overall, this patient remained in a stable clinical condition with continuous improvement in the symptoms. The patient did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.