Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Alcoholic liver cirrhosis,
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned in part.

This is a male patient with a past medical history significant for alcoholic liver cirrhosis, status post transjugular intrahepatic portosystemic shunt (TIPS) who presented to the emergency department with a 1-2 week history of abdominal pain and distention that became progressively worse and was associated with mild shortness of breath and with lower extremity edema. The patient complained of abdominal pain. He was already seen by his primary care physician, who prescribed Levofloxacin and told him to come to the emergency department.

The patient was in no acute distress. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was distended with a reducible umbilical hernia. There was 3 plus (+) pitting edema in the lower extremities. The rest of the exam was unremarkable.

The patient was admitted to the hospital with decompensated alcoholic liver cirrhosis with ascites, umbilical hernia, and hyponatremia. In the hospital, the patient was seen by a hepatologist who recommended a computed tomography (CT) scan of the abdomen and pelvis, a continuation of a home regimen of furosemide, and spironolactone. The patient was recommended treatment with Levofloxacin for prophylaxis of spontaneous bacterial peritonitis, as well as treatment with albumin. The patient was seen by general surgery for evaluation of an umbilical hernia. The hernia was reducible, there were no signs of incarceration or strangulation. No surgical intervention was recommended. Subsequently, the patient underwent large-volume paracentesis and 7.5 liters (L) of acidic fluid was drained. The culture was negative. The patient underwent transjugular intrahepatic portosystemic shunt (TIPS) revision. He had some abdominal pain that was relieved by Tramadol. His hyponatremia resolved. The patient continued to receive treatment with oral diuretics including furosemide and spironolactone. His clinical condition gradually improved, and the patient was discharged from the hospital. At issue is the medical necessity of an inpatient stay.

The health plan, in its determination of medical necessity, acted reasonably, with sound medical judgment and in the best interest of the patient, in part. Since the patient underwent revision of TIPS, the inpatient status was indicated for that day, when the patient underwent the procedure and recovery. The admission for the rest of the days was not indicated due to the fact that the ascites was not associated with hemodynamic instability, peritoneal signs on the exam, severe pain requiring frequent administration of intravenous pain medications.

The high-volume paracentesis, which was performed during the hospital stay, did not require admission at the acute inpatient level of care, especially when the fluid analysis did not show evidence of spontaneous bacterial peritonitis.

However, according to Medicare guidelines, TIPS is an inpatient only procedure, and since the patient underwent revision of TIPS, the inpatient status was indicated for that day, when the patient underwent the procedure and recovery. Following the procedure the patient remained in stable clinical condition; therefore, the rest of the hospitalization could be conducted at a lower level of care.