Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Ascites; Paracentesis
 
Treatment:  Inpatient Admission

The insurer denied the Inpatient Admission.  The denial was upheld.   

This is a male patient with a history of cirrhosis, ascites, umbilical hernia, and liver cancer pending a liver transplant.  He presented to the Emergency Department (ED) with complaints of abdominal pain and distension with associated shortness of breath; his vital signs were stable.  Laboratory work up was performed revealing a white blood cell (WBC) count 5.8, platelet count 194, creatinine 1.0, and (INR) was 1.38.  It was reported that several weeks prior to presentation he had a paracentesis; 8 liters of fluid was removed.  Gastroenterology consulted on the patient.  A planned paracentesis was scheduled and the patient was placed on a fluid restriction.  The patient underwent a paracentesis; 7.5 liters of clear yellow fluid was removed.  He tolerated the procedure well and was discharged home with outpatient instructions. 

According to MCG General Recovery Care, 23rd Edition, General Admission Criteria GRG: CG-GAC (ISC GRG), admission is indicated for 1 or more of the following: Hemodynamic instability; Hypertension requiring inpatient treatment; Acute cardiac or peripheral ischemia; Cardiac arrhythmias of immediate concern; Severe heart failure; Respiratory abnormalities; Severe airflow or ventilation abnormalities; Impending or actual respiratory arrest; Neurologic abnormalities; New-onset severe neurologic findings; Suspected acute intra-abdominal process; Severe physiologic disorder; Abdominal abnormalities; Acute renal failure. . . .  This patient did have the indications for admission based upon the above criteria.

Furthermore, as per MCG Inpatient and Surgical Care, 23rd Edition, Liver Disease Complications ORG:M- 570 (ISC) admission is indicated for 1 or more of the following: Hepatic encephalopathy that is moderate to severe or insufficiently responsive to observation care treatment; hemodynamic instability; Tachypnea (e.g. due to ascites) that persists despite emergency department and observation care treatment; Spontaneous bacterial peritonitis (ascitic fluid polymorphonuclear cell count of 250 cells/mm3 (0.25 x109/L) or more); Suspected infected ascites; Severe hepatitis (e.g. aspartate aminotransferase [AST] or alanine aminotransferase [ALT] level 15 times upper limit of normal or higher); Prothrombin time of 20 seconds or more (or INR of 2 or more); Prothrombin time greater than 15 seconds (or INR greater than 1.5) accompanied by any degree of hepatic encephalopathy; alcoholic hepatitis requiring treatment; Chronic liver disease (liver disease of any type for more than 26 weeks) or cirrhosis complicated by 1 or more of the following: Acute exacerbation of liver disease indicated by ALL of the following: Total serum bilirubin of 5 mg/dL (86 micromoles/L) or more; Other condition, treatment, or monitoring requiring inpatient admission.  None of these conditions were present in this patient; therefore, he did not require acute inpatient admission.  Therefore, this patient did not require acute hospitalization but rather observation care.

The health care plan did act reasonably, with sound medical judgment and in the best interest of the patient in denying this admission, as this patient could have been managed in an observation status.  

The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.