Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anemia, Cryptogenic Cirrhosis. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the inpatient hospital stay. 
The determination is overturned. 

This patient with multiple medical problems, including cryptogenic cirrhosis, with hepatic encephalopathy, chronic respiratory failure with oxygen dependence, esophageal varices, and previous banding jejunal arteriovenous malformations (AVMs), presented to the hospital from a rehabilitation facility, with severe anemia and hemoglobin of 5.2. On arrival in the emergency department (ED), the patient was awake and alert and reported no abdominal pain, chest pain, shortness of breath, or loss of consciousness. The patient denied any black or bloody stools. The vital signs on arrival included a temperature of 98.6 degrees Fahrenheit, heart rate of 73, and blood pressure of 104/54. On exam, the patient was ill-appearing and pale. The rectal exam showed dark brown stool, no bright red blood per rectum, and guaiac was sent. Bilateral lower extremity edema was also noted. The ED contacted gastroenterology, given the patient's prior history of gastrointestinal (GI) bleeding. They also consulted interventional radiology, as the patient was due for a paracentesis. 

The gastroenterology team assessed the patient and reviewed the history, including recurrent GI bleeding, child Pugh category C cryptogenic cirrhosis, with a Model for End-Stage Liver Disease (MELD) score of 19. The patient was not deemed a candidate for transjugular intrahepatic portosystemic shunt (TIPS) or a liver transplant due to significant deconditioning and malnutrition. 2 units of packed red blood cells were given in the ED, with a subsequent repeat hemoglobin of 7.3. 

Vital signs included a normal temperature, pulse rate of 64, respirations of 18, blood pressure of 108/56 with 100% oxygen saturation while the patient was on 7 liters (L) of oxygen by nasal cannula. There was 3 plus (+) pitting of the lower extremities. The potassium was 5.3, creatinine was 1.3, and blood urea nitrogen (BUN) is 51. The total bilirubin was 4.8. The international normalized ratio (INR) was 1.5. The MELD score remained at 19. The gastroenterologist recommended starting with a computed tomography (CT) scan of the abdomen and pelvis without contrast to rule out hemoperitoneum. They recommended a restrictive transfusion strategy for a hemoglobin less than 7 and platelets less than 50,000. The platelet count was 49,000 on with a recheck of 55,000. The patient was made nothing by mouth (NPO) after midnight, in case an endoscopic procedure was necessary. They agreed with obtaining a diagnostic paracentesis to rule out spontaneous bacterial peritonitis. Chronic medications for esophageal varices, hepatic encephalopathy, and coagulopathy were continued. 
The patient was also assessed by the palliative care team for goals of care discussion. The patient expressed wishes to pursue ongoing interventions and not palliative measures. 

The MELD score was unchanged, total bilirubin still 4.8, and the INR remained at 1.5. The patient denied any signs of bleeding, abdominal pain, nausea, or vomiting. The hemoglobin has improved to 8.1 g/dL, and platelet count was 51,000. The CT scan of the abdomen and pelvis showed a slight decrease in large volume ascites, positive anasarca, layering left pleural effusion with compressive atelectasis. The medical team considered the possibility of hemolytic anemia, given the indirect bilirubin elevation. They ordered appropriate studies. The gastroenterologist noted no overt bleeding, discussed with the patient, and suggested there was no utility to performing an endoscopic evaluation at this time. They suspected slow oozing AVMs. Up to this point, the patient was treated with an octreotide drip, given the prior history of esophageal varices with bleeding. 

The anemia studies came back suggestive of iron deficiency, with no hemolysis evidence. Incidentally, coronovirus disease (COVID) polymerase chain reaction (PCR) testing came back positive. COVID antibodies were checked, and they were positive as well, suggestive of previous exposure and development of immunity. The hepatology team assessed the patient and recommended treatment with intravenous (IV) Lasix in the hospital, withholding aldactone due to hyperkalemia.  The medical team established a discharge plan back to the nursing home, pending insurance authorization. 

The hepatology team decided to pursue an esophagogastroduodenoscopy (EGD). Electrolytes and renal function continued to improve. He was also started on ceftriaxone, possibly due to suspicion of a variceal bleed. 
 An esophagogastroduodenoscopy (EGD) was scheduled for the following day, and interventional radiology was consulted for a large-volume paracentesis. Lasix and Aldactone were held, and the patient was given 25 grams (g) of intravenous (IV) albumin due to a trend up in the creatinine to 1.4. A paracentesis was accomplished, with 13 liters (L) of fluid removed. 

The hemoglobin dropped again to 6.7, and 1 additional unit of packed red blood cells was provided. The platelet count was low at 44,000. The EGD was rescheduled for the following day. A posttransfusion hemoglobin was checked later in the day, and it was 8.2 g/dL. The following day, the hemoglobin was down again to 7.5 g/dL, with a platelet count of 52. The hepatologist reassessed the patient and postponed the EGD procedure for another day.  The EGD was done and showed no obvious bleeding, healing esophageal ulcers status post banding, small varices, moderate to severe hypertensive portal gastropathy with old blood seen in the stomach. The patient was started on Carafate, continued on propranolol and a proton pump inhibitor (PPI). They also recommended checking the patient for human immunodeficiency virus (HIV) and cytomegalovirus (CMV). 

The patient was assessed by physical therapy. They recommended a skilled nursing facility, and the case manager made arrangements. A repeat COVID PCR on this day came back negative. 

At issue is the medical necessity of an inpatient level of care. 

Inpatient hospitalization was warranted in this case. 

This is a complex patient with advanced cryptogenic cirrhosis, esophageal varices, ascites who comes into the hospital with severe anemia. Given the patient's prior history of GI bleeding and multiple predisposing factors for GI bleeding, it was reasonable that this was acute blood loss anemia. Also, this patient had decompensated liver cirrhosis, with a MELD score of 19. The documentation describes a very ill patient at high risk for decompensation and death. It was reasonable and within the standard of care, to expect the patient's presentation to require an inpatient level of care. This patient required 4 units of packed red blood cells during the hospital stay. There was evidence of severe thrombocytopenia, with the platelet counts dipping below 50,000. The INR was elevated, increasing the risk of bleeding. The patient had a known history of esophageal varices and had undergone banding. The EGD showed old blood in the stomach. The patient required a high volume paracentesis and required IV albumin. The electrolytes were being affected, and the renal function, by large volume shifted and there was the need for diuretic therapy. The patient's expected mortality was extremely high, and a lower level of care was not appropriate. 

Based on the Milliman criteria, the patient had evidence of high-risk thrombocytopenia, a clinical indication for admission to inpatient care level. There were renal dysfunction elements, the need for multiple transfusions, and volume replacement, which persisted beyond a lower level of care. When the hospitalization is reviewed in its entirety, an inpatient care level was medically necessary.