Appeal type: Medical necessity
Decision: Upheld

Diagnosis: hypertriglyceridemia
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.
 
This is an adult with a past medical history that includes hypertension and hyperlipidemia. He presented to the emergency department (ED) having been sent by his primary care provider for triglycerides over 1,000. He was asymptomatic.

He was evaluated in the ED (emergency department), who discussed the case with the primary care provider, and planned for admission to Internal Medicine, with an expected need for two days of inpatient care for "optimization."

His initial lab work was largely unremarkable other than a mild transaminitis and a mildly elevated blood glucose of 123. Vitals and the remainder of the exam were reassuring.

A lipid panel showed triglycerides of 266. He was started on gemfibrozil (Lopid) and advised to follow-up with his primary care provider. 

Triglycerides of over 1,000 would be considered severely elevated by most criteria.  However, even in this category, lifestyle modification is the initial recommendation, with reduction of sugars and fats as well as alcohol.  In general, there is no mention of hospitalization for initial treatment of unstable hypertriglyceridemia. 

As this appears to be a primary hypertriglyceridemia (i.e., not due to another cause, such as diabetes mellitus, medications, or alcohol), it is likely familial and associated with some risk of pancreatitis in the long-term.  However, there was no pancreatitis in this case. Even if pancreatitis was present, admission would not be warranted for the patient. There are a number of "worrisome features" of a hypertriglyceridemia-associated pancreatitis, such as hypocalcemia, lactic acidosis, fever, tachycardia, tachypnea, or elevated white cell count, which would necessitate plasmapheresis or other hospital-based treatments.  None of those were present here.

His ultimate triglyceride level of 266 would be considered consistent with moderate hypertriglyceridemia, and treatment in that context is based upon heart disease risk. As the patient's risk appears to be low, conservative measures, such as fibrates and dietary / other lifestyle modifications, would be considered appropriate. 

There did not appear to be any factors in the patient's hypertriglyceridemia that warranted treatment other than standard medical therapy and lifestyle modifications, which would typically be recommended by a primary care provider in an outpatient setting. None of the standard therapy would typically take place in a hospital, particularly in an inpatient setting. This is confirmed by the fact that the medication (gemfibrozil) that the patient was given was essentially given to him immediately prior to his discharge, which occurred approximately 12 hours after his admission history and physical was completed.

His hypertriglyceridemia did not have worrisome features that warranted treatment beyond standard medical therapy and lifestyle modification, regardless of whether it was in the severe range (as initially suspected) or the moderate range (as ultimately demonstrated).

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for hospital services is not substantiated.