Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal.
Treatment: Inpatient hospital stay.
The health plan denied the inpatient stay as not medically necessary.
The reviewer has upheld in whole the health plan's determination.

The patient has a medical history of hepatic steatosis, hypertension, chronic cystitis, and chronic alcohol abuse. She presented to the emergency department with abdominal distention and pressure for 3 weeks. Vital signs were notable for elevated blood pressure of 137/85. Physical examination was notable for a soft, distended, nontender abdomen with normal bowel sounds and positive fluid wave. Labs showed low platelet count of 119, low potassium of 2.7, elevated aspartate aminotransferase of 98, elevated alkaline phosphatase of 122, elevated bilirubin of 1.8, and elevated international normalized ratio of 1.35. Computed tomography scan of the abdomen and pelvis showed hepatomegaly and abnormal heterogenous appearance of the liver with nodular contour suggestive of hepatic cirrhosis, large areas in the liver concerning for diffuse/multifocal hepatocellular carcinoma with presence of moderate abdominal pelvic ascites and diffuse mesenteric edema, and suggestion of bulky porta hepatis lymphadenopathy. She was treated with intravenous ceftriaxone. She was placed on Clinical Institute Withdrawal Assessment (CIWA) protocol. Gastroenterology consultation concluded that she had new-onset ascites, elevated transaminases, and concern for alcoholic hepatitis (Model for End-Stage Liver Disease-sodium (MELD-NA) score was reported to be 15 and Maddrey's discriminant function was 14); the recommendation was diagnostic and therapeutic paracentesis including cytology, daily labs, consider diuretics, consider magnetic resonance imaging (MRI), and monitor for signs of withdrawal. The next day she denied abdominal pain. Labs showed low platelet count 207, low potassium of 2.9, low albumin of 3.1, elevated aspartate aminotransferase of 88, and elevated bilirubin of 1.7. MRI of the abdomen showed hepatomegaly with findings suggestive of hepatic cirrhosis but no convincing evidence of hepatocellular carcinoma or abdominal lymphadenopathy, and large abdominal ascites. Labs then showed low platelet count of 112, low sodium of 135, low potassium of 3.1, low albumin of 3.0 elevated bilirubin of 1.5, and elevated aspartate aminotransferase of 77. She underwent ultrasound-guided paracentesis, with removal of 2.75 Liters of ascites, with unremarkable cytology result. She was discharged with a plan for Primary Care and Gastroenterology follow-up. 

In this case, the patient presented with increased ascites and abdominal discomfort in the setting of new diagnosis of cirrhosis complicated by portal hypertension; paracentesis was warranted and performed, in accordance with guidelines, but was a low-volume paracentesis [1]. Low-volume paracentesis is generally not associated with circulatory or renal dysfunction; the patient tolerated paracentesis without hemodynamic or renal decompensation, and there was no evidence of spontaneous bacterial peritonitis [2-6]. Imaging ultimately did not show hepatocellular carcinoma or other complications such as portal venous thrombosis which would have incited worsening ascites. There was no hemodynamic instability, imaging evidence of biliary obstruction, biliary or pancreatic mass, bile leak, ascending cholangitis, hepatic abscess, or other complications which would require the inpatient level of care [7,8]. She did not have documented alcohol withdrawal [9,10]. The care provided could have been provided without the inpatient level of care, and there were no complications such as active bleeding, infection, or alcohol withdrawal to warrant the inpatient level of care.
Additionally, Per the Milliman Care Guidelines for Liver Disease Complications, inpatient admission is not supported by the provided documentation.