Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal and Leg Swelling
Treatment: Inpatient Emergency Admission
The insurer denied the inpatient emergency admission.
The health plan's determination is upheld.

The patient is a male who was admitted with abdominal, scrotal, and leg swelling. He has a known history of cirrhosis secondary to hepatitis C. He appeared pale and jaundiced on arrival. The patient denied any fevers or chills but he was dyspneic. The patient's temperature was normal, his heart rate was 111, and the blood pressure was 109/62. On examination, he was noted to have no jugular vein distention (JVD). He had a protuberant and tympanic abdomen, with significant swelling of the penis and 2 plus (+) pitting edema of the lower extremities. His white blood cell count was slightly elevated at 11.4, with a hemoglobin of 12.5. His urinalysis was fairly unremarkable. His sodium was 134, with a creatinine of 1.44 and his lipase was 14. The liver enzymes were mildly elevated, the aspartate aminotransferase (AST) at 70, with a normal alanine aminotransferase (ALT) of 45. The chest x-ray showed a right lower lung infiltrate suspicious for pneumonia.

A bedside ultrasound was completed in the emergency department (ED) showing significant ascites. Interventional radiology was unavailable for a paracentesis that evening and it was scheduled for the next day. The suspicion for spontaneous bacterial peritonitis per the emergency department (ED) physician was low. No antibiotics were given.

The patient was admitted to the hospitalist service, who treated the patient with Lasix 40 milligrams (mg) twice daily and Spironolactone 100 mg. A formal interventional radiology consultation and a urology consultation for the penis swelling were placed. They also consulted the gastroenterologist for optimization of cirrhosis therapy.
The next day, the patient underwent a therapeutic and diagnostic paracentesis. The peritoneal fluid analysis shows 4 liters of yellow fluid was removed, with 18 white blood cells. His international normalized ratio (INR) check was 1.15. The patient's creatinine improved to 1.14. He did not tolerate Spironolactone due to hypotension and was started on Midodrine 10 mg 3 times daily. The abdominal distention improved after the paracentesis, and the patient requested to go home. The medical team stated the patient should have routine outpatient paracentesis periodically for therapeutic purposes. The discharge was planned however, given extensively documented nursing concerns, discharge was held for an extra day.

The health plan acted reasonably, with sound medical judgment, and in the patient's best interest. An inpatient hospitalization is not warranted in this case.

The requested health service/treatment of inpatient emergency was not medically necessary for the patient. Patients with hepatic cirrhosis are often evaluated and treated in the hospital setting, under observation care, with large-volume paracentesis and adjustment of their longstanding regimen. Decompensations of hepatic cirrhosis are common. Admission indications include spontaneous bacterial peritonitis, hepatic encephalopathy, severe coagulopathy, significantly elevated discriminant function score, and Child-Pugh criteria. The patient in this presentation did not have high-risk features. Low blood pressures are very common in patients with hepatic cirrhosis. It is not a sign of sepsis or shock but a function of the underlying disease. As a result, low blood pressure is tolerated, while diuresis is continued. Reviewing this hospitalization, there were no high-risk features warranting an inpatient hospitalization.