Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment is an inpatient admission 
The insurer denied coverage for an inpatient admission 
The denial is upheld

The patient has a history of alcohol abuse, chronic pancreatitis, recurrent abdominal pain, and hypertension (HTN). The patient presented to the emergency room with abdominal pain and vomiting. The patient received diagnostic testing, IV (intravenous) fluids, antiemetics, pain medication, and a GI (gastrointestinal) consultation. The insurer has denied coverage for an inpatient hospital admission as not medically necessary. They noted that the patient was not unstable and there was no report of any serious or severe findings. The patient did not have unstable vital signs, evidence of bacteria in the blood, a tear of the large abdominal blood vessel, dying intestines, a blockage of bowels, or a need for open abdominal surgery. The treating provider ordered an inpatient (IP) hospital admission. The treating provider is requesting plan approval for an inpatient (IP) hospital admission.

Despite the patient's presentation the care as provided could have been rendered in its entirety at a lower level of care. The patient had no evidence of a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such the care could have been rendered at a lesser level. Therefore, the health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting.

"Acute pancreatitis is a necro-inflammatory disease of the exocrine pancreas that is characterized by inappropriate activation of zymogens, infiltration of the pancreas by inflammatory cells, and destruction of the pancreatic exocrine cells. Acute pancreatitis can progress to a severe life-threatening disease. Currently there is no pharmacotherapy to prevent or treat acute pancreatitis. One of the more common factors associated with acute pancreatitis is alcohol abuse. Although commonly associated with pancreatitis alcohol alone is unable to cause pancreatitis. Instead, it appears that alcohol and its metabolic by-products predispose the pancreas to damage from agents that normally do not cause pancreatitis, or to more severe disease from agents that normally cause mild pancreatic damage. Over the last 10 to 20 years, a tremendous amount of work has defined a number of alcohol-mediated biochemical changes in pancreatic cells. Among these changes are: Sustained levels of intracellular calcium, activation of the mitochondrial permeability transition pore, endoplasmic reticulum stress, impairment in autophagy, alteration in the activity of transcriptional activators, and colocalization of lysosomal and pancreatic digestive enzymes. Elucidation of these changes has led to a deeper understanding of the mechanisms by which ethanol predisposes acinar cells to damage." (Clemens, et al., 2016).                                                         

The insurer's denial of coverage for an inpatient hospital admission is upheld. Medical Necessity is not substantiated.