Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Digestive System/Gastrointestinal. 
Treatment:  Inpatient Hospital. 

The insurer denied inpatient admission.  The denial is upheld in whole.

The patient is a male with medical history of cirrhosis complicated by portal hypertension with grade 3 esophageal varices, alcohol abuse, intracranial hemorrhage with craniectomy, alcohol withdrawal seizures, delirium tremens, diabetes mellitus, hypertension, and gastrointestinal bleeding.  He presented to the emergency department with worsening abdominal distention, lower abdominal pain, and dyspnea for 10 days, and melena for a few days.  He had not been taking his diuretics routinely.

Vital signs were unremarkable.  Physical examination was notable for ascites, lack of tenderness, and normal bowel sounds.  Labs showed low white blood count of 4.7 thousand per microliter (K/uL), low hemoglobin of 7.1 grams per deciliter (g/dL) and hematocrit of 24.4%, low platelet count of 73 K/uL, low albumin of 2.9 g/dL, elevated aspartate aminotransferase of 43 units per liter (U/L), elevated alkaline phosphatase of 202 U/L, and elevated bilirubin of 1.6 milligrams per deciliter (mg/dL).  Guaiac test was positive.  Computed tomography scan of the abdomen and pelvis showed cirrhosis and ascites.  He was treated with famotidine.  He was made nothing by mouth (NPO).

Gastroenterology consultation concluded that he had progressive dyspnea likely due to worsening ascites, no evidence of active or overt gastrointestinal bleeding, and end-stage liver disease; the recommendation was large-bore intravenous access, intravenous fluids, follow blood count and transfuse as needed, follow liver enzymes and international normalized ratio, correct coagulopathy with vitamin K, avoid anti-platelet agents and anticoagulation, diagnostic and therapeutic paracentesis, salt water restriction, diuretics as tolerated, proton pump inhibitor and Carafate, nadolol, alcohol cessation and counseling, Clinical Institute Withdrawal Assessment (CIWA) protocol and withdrawal management, and consideration for endoscopy when international normalized ratio is less than 1.5.  He underwent paracentesis with removal of 4 liters (L) of fluid.  He was transfused with one unit of packed red blood cells and fresh frozen plasma.  He was initiated on vitamin K, propranolol, and pantoprazole.  He reported no acute events overnight.  He was discharged with a plan for Primary Care follow-up.

The health plan's determination is upheld.

In this case, the patient presented with increased ascites and peripheral edema in the setting of cirrhosis complicated by portal hypertension; paracentesis was warranted and performed, and diuretics were administered, in accordance with guidelines [1].  Low-volume paracentesis is generally not a risk for circulatory and renal dysfunction; the patient tolerated diuretics without hemodynamic or renal decompensation, and there was no evidence of spontaneous bacterial peritonitis [2,3,4].  Although there was melena on presentation, the hemoglobin responded well to transfusion and remained stable; there was no visible ongoing bleeding [5,6].  The patient did not have any signs of protracted alcohol withdrawal [7].  The patient remained stable, and no intervention was performed which could not have been performed at a lower level of care.  The monitoring, specialist consultations, paracentesis, and dialysis performed could be performed at a lower level of care status.  Therefore, the inpatient admission is not medically necessary.