Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hepatic Mass

Treatment: Inpatient admission

The insurer denied the inpatient admission

The denial was upheld.

This is a male patient with a medical history of constipation. He presented to the Emergency Department (ED) for assessment and management of a 5.5 x 5.1 x 3.6 cm mass in the right hepatic lobe found incidentally on an outpatient sonogram performed to assess for a hernia. The patient had developed periumbilical abdominal pain partially responsive to cathartics a few months prior to presentation. The patient's vital signs were notable for blood pressure 103/67, heart rate 91, respiratory rate 24, temperature 98.2 F and oxygen saturation 100% in room air. The patient's heart and lung exams were also unremarkable. The patient's abdomen was flat with mild right upper quadrant discomfort on palpation and a palpable liver edge. There were no masses, splenomegaly, ascites, rebound or guarding on abdominal exam. The patient refused pain medications. The patient's computed tomography (CT) scan of the chest, abdomen and pelvis was performed showed a 5.2 x 1.5 x 3.9 cm hypodense mass in the right lobe of the liver without arterial enhancement and without mass effect. Oncology consulted with recommendations for admission for further assessment. The patient's repeat labs showed white blood count 5.4, hemoglobin 12.4, platelets 256, albumin 4.2, AST 45, ALT 144, AP 204, and bilirubin 0.6. The patient was discharged home to complete an outpatient work-up including magnetic resonance (MRI) imaging.
 
According to a review regarding the approach to elevated liver function tests (LFT) from UptoDate, the authors states that the initial evaluation of a patient with abnormal liver biochemical and function tests includes obtaining a history to identify potential risk factors for liver disease and performing a physical examination to look for clues to the etiology and for signs of chronic liver disease. Subsequent testing is determined based on the information gathered from the history and physical examination as well as the pattern of test abnormalities. The history should determine if the patient has had exposure to any potential hepatotoxins (including alcohol, recreational drugs, herbals and medications), is at risk for viral hepatitis, has other disorders that are associated with liver disease, or has symptoms that may be related to the liver disease or a possible predisposing condition. The physical examination may suggest the presence of liver disease and may point to the underlying cause of the liver disease. These findings include: temporal and proximal muscle wasting suggest longstanding disease; stigmata of liver disease include spider nevi, palmar erythema, gynecomastia, and caput medusa; ascites or hepatic encephalopathy may be seen in patients with decompensated cirrhosis; dupuytren's contractures, parotid gland enlargement, and testicular atrophy are commonly seen in advanced alcoholic cirrhosis and occasionally in other types of cirrhosis; an enlarged left supraclavicular node (Virchow's node) or periumbilical nodule (Sister Mary Joseph's nodule) suggest an abdominal malignancy; increased jugular venous pressure, a sign of right-sided heart failure, suggests hepatic congestion; a right pleural effusion, in the absence of clinically apparent ascites, may be seen in advanced cirrhosis; neurologic and psychiatric signs and symptoms may be seen in Wilson's disease.


The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for inpatient admission is not substantiated.  The insurer's denial should be upheld.