Appeal type: Medical necessity
Decision: Overturned

Diagnosis: hypomagnesemia.

Treatment is inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

The patient is an adult female with a past medical history of cirrhosis. The patient presented with complaints of abdominal pain, as well as lower extremity pain and swelling, and dyspnea. On physical examination, the patient had expiratory wheezing as well as a fluid wave on her abdominal examination. The patient's laboratories revealed hyperbilirubinemia, cholestasis, and elevated lipase. The patient has evidence of ascites. The patient received intravenous magnesium, ceftriaxone, morphine, thiamine and Ativan. The patient underwent a large volume paracentesis where 3900 cubic centimeters (cc) of fluid was removed.

The patient was also diagnosed with an asthma exacerbation as well as hypomagnesemia with a prolonged QT interval (interval on an ECG (electrocardiogram)). Without magnesium replacement, the patient may have been at further risk for a more serious cardiac arrhythmia. The patient needed to receive steroids and nebulizer treatments for her asthma. Therefore, the inpatient admission was medically necessary for this patient.

"There was no significant difference in 60-month transplant-free survival between patients with grade 1 vs (versus) grade 2 or 3 ascites (36% vs 43% (percent)) but survival was significantly lower when both groups were compared with patients without ascites (68%; P (probability) < (less than) 0.001 for both comparisons). However, the grade of systemic inflammation and the rate of complications were significantly greater in patients with grade 1 ascites than in patients without ascites, but significantly lower than in patients with grade 2 or 3 ascites. Development of grade 2 or 3 ascites did not differ significantly between patients with no ascites vs grade 1 ascites (10% vs 14%). There was no significant difference in 36-month transplant-free survival between patients with ascites responsive to medical treatment vs recurrent ascites (78% vs 62%), whereas patients with refractory ascites had significantly lower survival than patients with responsive or recurrent ascites (23%; responsive vs refractory ascites P<.001; recurrent vs refractory ascites P = .022)." (Tonon, M., et al. 2021).

"Conclusion: Paracentesis is under-utilized among cirrhotic patients presenting with ascites and is associated with decreased in-hospital mortality. These data support the use of paracentesis as a key inpatient quality measure among hospitalized adults with cirrhosis." (Gaetano, J. N., et al. 2016).

"Conclusion: The prevalence of hypomagnesaemia in internal medicine is very high. It is associated with higher mortality and longer hospital stay in our population. It can be a useful tool in predicting morbidity and mortality. Although no causal role can be defined for it at present, the low cost and minimal discomfort of measuring magnesium justifies its routine measurement and replacement in patients hospitalized in internal medicine." (Wolf, F., & Hilewitz, A. 2014).                                                         

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient hospital admission is substantiated.