Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Epigastric Pain
Treatment: Inpatient hospital services 
The health plan denied the requested inpatient hospital services as not medically necessary. 
The health plan's determination is overturned.

The patient is a female with a past medical history significant for hypertension who presented to the emergency department with complaints of epigastric abdominal pain. She stated that the pain started one day before her admission. She described the pain as 10/10 in severity, dull, radiating to the back, and associated with nonbloody, non-bilious vomiting. The patient also stated that she had 2 episodes of watery diarrhea. She admitted to drinking alcohol 3 - 4 times a week. The patient denied any previous similar episodes.
The review of systems was negative for chest pain, shortness of breath, changes in urinary habits, and syncope. In the emergency department, the patient underwent abdominal ultrasound that demonstrated increased liver echogenicity, no biliary stones, and no biliary duct dilation. On the physical exam, the patient was afebrile. Her blood pressure was 143/83 millimeters of mercury (mmHg), with a pulse rate 78 beats per minute (bpm), a respiratory rate of 16 breaths per minute, and an oxygen saturation of 99% on room air.
The patient had dry oral mucosa. The patient had a regular rate and rhythm, without murmurs, rubs, or gallops. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft with some epigastric tenderness, but no guarding or rebound. Laboratory evaluation revealed that the sodium was 134, with a potassium of 3.7, a chloride of 90, a bicarbonate of 36, a blood urea nitrogen (BUN) of 4, a creatinine of 0.4, and a glucose of 123. The alanine aminotransferase (ALT) was 136, with an aspartate aminotransferase (AST) of 161. The lipase was 2163. The white blood cell count was 5.8, with a hemoglobin of 15.1, a hematocrit 43.6, and platelets of 277.
The patient was admitted to the hospital with acute pancreatitis, likely secondary to alcohol use. Another diagnosis at the time of admission was dehydration secondary to vomiting, alkalosis likely secondary to vomiting, and alcoholic hepatitis.
The patient was admitted to the hospital and was kept nothing by mouth (NPO). She received treatment with intravenous fluids, antiemetics, and pain medications. Clinical Institute Withdrawal Assessment (CIWA) protocol was initiated.
As a result of the treatment provided in the hospital, the patient's clinical condition significantly improved. She tolerated her diet before discharge and was discharged from the hospital with a recommendation to follow up with her primary care physician.
At issue is the medical necessity for the inpatient hospital services.

I overturn, in whole, the health plan's determination of medical necessity.

The patient presented to the hospital with acute pancreatitis that necessitated keeping the patient NPO, at least initially, providing aggressive resuscitation with intravenous fluids, supportive care with antibiotics, intravenous pain medications, as well as close monitoring of vital signs while receiving intravenous fluids.
According to the patient's presentation, she had acute pancreatitis. Based on the current standards of care, treatment of acute pancreatitis is typically supportive. Patients who develop complications may require specific additional treatment.
The basic treatment of acute pancreatitis includes early goal-directed fluid resuscitation, analgesia and nutritional support.
So, taking into consideration current standards of care, this patient required aggressive fluid resuscitation, administration of pain medications, frequent monitoring of vital signs, and laboratory results.
In order to provide these treatments in a timely manner, admission at the acute inpatient level of care was completely justified.
The complexity of the treatment completed justified admission at the acute inpatient level of care.