Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abnormal blood tests. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. The health plan's determination is upheld. 

The patient is a female with a medical history of myositis undifferentiated connective tissue disease. She presented to the emergency department with elevated liver enzymes. Testing showed an elevated aspartate aminotransferase (AST) of 1,380 units per liter (U/L) and an elevated alanine aminotransferase (ALT) of 1,044 U/L. Laboratory studies showed a low white blood cell count of 3.2 kilos per microliter (K/uL), an elevated AST of 649 U/L, an elevated ALT of 911 U/L, an elevated creatinine kinase (CK) of 1,582, and an elevated international normalized ratio of 1.2. A right upper quadrant ultrasound showed coarsened hepatic echotexture, possibly reflecting hepatic steatosis/parenchymal disease. A computed tomography (CT) scan of the chest showed no evidence for primary intrathoracic malignancy or metastatic disease, clear lungs with no suspicious pulmonary nodule or interstitial lung disease, lack of thoracic lymphadenopathy, and a nodular thyroid gland was partially imaged. A CT scan of the abdomen and pelvis showed mild apparent wall thickening of the stomach which may have been related to under distention, nonspecific, and no evidence of malignancy in the abdomen or pelvis; uterine leiomyoma; and a right ovary probable dominant follicle measuring 2.2 centimeters (cm). A Rheumatology consultation noted asymptomatic CK elevation with rapidly rising transaminases, which were now declining, and a negative broad serologic work-up for connective tissue and vasculitis; the differential diagnosis was myositis and possible paraneoplastic effect; the recommendation was evaluation by Hepatology and Dermatology, a CT scan of the chest, abdomen, and pelvis, magnetic resonance imaging (MRI) of the bilateral thighs, repeat serologic testing, and a pregnancy test. A chest x-ray showed no acute intrathoracic abnormality. A Dermatology consultation noted a dorsal hand rash, an elevated CK, and liver enzymes which were concerning for an underlying autoimmune process secondary to myositis versus dermatomyositis versus lupus versus paraneoplastic effect versus vasculitis process; the recommendation was for cancer screening, autoimmune laboratory studies, a punch biopsy, a follow up autoimmune panel, and an outpatient Dermatology appointment. The patient underwent a punch biopsy of her hand rash. Later in the patient's stay, her AST was 180 U/L and her ALT was 540 U/L. MRI of the bilateral thighs demonstrated nonspecific myositis involving the bilateral abductor magnus, semimembranosus, and biceps femoris muscles, with findings asymmetrically more prominent on the left and most notable in the mid portions of the thighs. A Surgery consultation recommended an outpatient muscle biopsy. 

At issue is the medical necessity of an inpatient admission. 
I uphold the health plan's determination, in whole. 

The inpatient level of care is not supported as medically necessary. 

The patient presented with severe elevation in transaminases, but these steadily and rapidly improved during her stay. There was no evidence of acute liver failure, ascending cholangitis, hepatic abscess, or other complications which would have required the inpatient level of care [1-4]. She was assessed to have myositis and a possible autoimmune process; however, she did not develop significant complications of this during her stay, and the workup did not reveal a definitive cause - further evaluation was deferred for outpatient care [5-8]. The care provided, including laboratory studies, observation, specialist consultations, punch biopsy, and imaging, could have been performed without the inpatient level of care. 

Per the Milliman Care Guidelines for Liver Disease Complications and the Milliman Care Guidelines for Musculoskeletal Disease GRG, the inpatient level of care is not supported.