CLINICAL SUMMARY:
A 30-year-old patient arrived at the emergency room suffering from abdominal pain, nausea and vomiting. The patient’s symptoms had been occurring for the past six weeks and progressively worsened. The patient complained of pain in the upper abdomen that radiated to the back. The patient had a medical history of anxiety, asthma, depression, bipolar disorder, polysubstance abuse and alcohol abuse. The alcohol abuse included drinking one pint of hard alcohol a day for many years. ER test results showed the following: sodium 132, potassium 3.6, creatinine 0.54, ALT 170, AST 359, total bilirubin 1.7, lipase 548, WBC 7.64, hemoglobin 13.5, platelet 174. A urinalysis was positive for nitrites, leukocyte esterase and white blood cell count. The patient’s urine toxicology testing was positive for cannabinoids, cocaine and benzodiazepine. A computed tomography (CT) scan of the abdomen and pelvis showed mild to moderate acute interstitial pancreatitis, a small cyst in the tail of the pancreas, liver enlargement with fatty infiltration and an 11 mm enhancing mass in the right lobe of the liver that was well-circumscribed, indicating a probable atypical hemangioma.
Treating physicians admitted the patient with a diagnosis of alcohol-induced pancreatitis, transaminitis consistent with alcohol abuse, dependence, polysubstance use and a urinary tract infection. Vital signs upon admission were 97.9, 90-115, 13-22 and systolic BP of 139-166/ diastolic BP of 103-118. During the admission, the patient had nothing by mouth, receiving only fluids. The next morning, the patient continued to have pain and asked for IV pain medications and solid foods. Doctors discussed pain control with the patient and gradually starting a diet later in the afternoon. The attending nurse reported that the patient was unhappy about not being able to keep her 5-year-old in the room, and the patient decided to leave against medical advice (AMA).
INPATIENT STAY DENIAL
The insurance company denied the inpatient hospital stay for pancreatitis with symptoms of abdominal pain, nausea and vomiting. The denial stated that the insurance company could not approve inpatient level of care because it did not see improvement or persistence of the need for IV medicine to control vomiting, IV pain medication, issues with eating and drinking, high amylase test results and imaging to support organ problems or low blood oxygen levels that were reported in the patient’s records.
THE APPRISEMD METHOD
An AppriseMD physician advisor spoke with the insurance company medical director regarding the denial. The physician advisor reiterated the 30-year-old patient’s history of asthma, depression, anxiety, bipolar disorder and alcohol abuse and reviewed her evaluation for abdominal pain when arriving at the ER. The discussion reaffirmed the fact that on hospital day one, the patient was mildly hypertensive and tachycardic, and that doctors ordered a CT of the abdomen that demonstrated mild to moderate acute interstitial pancreatitis with an associated elevated lipase of 548. During the inpatient stay, the patient received IV fluids, IV morphine and IV magnesium with antiemetics. The AppriseMD physician advisor then discussed the fact that on hospital day 2, the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score was 0, and the patient left AMA. The insurance company reversed its initial denial after a review of the facts by the physician advisor, which also included a discussion that the patient met inpatient criteria for acute pancreatitis on admission. Even though this patient left AMA, this one midnight stay was successfully approved for inpatient level of care and the denial was overturned.