Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal/Other/Liver Mass.
Treatment: Surgical Services.

The health plan denied the request for surgery due to the lack of medical necessity.  The health plan's determination is upheld.

The patient is a woman who presented to the Emergency Department (ED) with a 2-day history of right lower quadrant abdominal pain. Upon examination at that time, she was found to have right lower quadrant abdominal tenderness at McBurney's point. She did not report any other symptoms such as fever, chills, nausea or vomiting, weight loss, night sweats, or history of hepatitis. While in the ED, the patient underwent a computed tomography (CT) of the abdomen and pelvis and a pelvic ultrasound exam that demonstrated a left adnexal cyst, a hepatic mass, and renal cysts. Her abdominal pain resolved while she was in the ED, and she was discharged to home with instructions for follow-up as an outpatient.

The patient saw her physician in the office. His note indicated that the patient's abdomen was soft, non-tender, and without palpable masses on physical examination at that time. The physician placed an order for a triple phase CT of the abdomen/pelvis and a chest CT.

The patient saw another physician in the office at a later date. At that time, she reported that she had been doing better and did not have any symptoms of abdominal pain. This physician requested a liver protocol magnetic resonance imaging (MRI) for surgical planning.

A CT of the chest, abdomen and pelvis was performed. This study showed innumerable simple appearing cysts throughout the liver and kidneys. Also seen were multiple, nonspecific enhancing hepatic lesions including a dominant right hepatic lobe mass measuring 9.6 x 6.8 x 8.3 centimeters (cm). The differential diagnosis for the nonspecific enhancing hepatic lesions included focal nodular hyperplasia and multiple hepatic adenomas. The dominant right hepatic lobe mass did not appear typical of either focal nodular hyperplasia or hepatic adenomas. Suggestions for definitive characterization of the nonspecific right hepatic lobe mass(es) included tissue correlation (biopsy) or contrast-enhanced abdominal MRI.

The patient's physician placed a request for authorization for a liver resection which is planned for later this week. The request for authorization was denied stating that there was no documentation showing that she meets criteria for a liver resection. There was no documentation showing that a complete work-up of the liver mass had been performed to determine the diagnosis of the mass and whether surgery is required.

The health plan's determination of medical necessity is upheld, in whole.

At the present time, with the information that is currently available for review, the inpatient liver resection is not medically necessary. The diagnosis of the liver mass may be determined via contrast MRI and/or biopsy. There are several possible etiologies for the liver mass, and each is managed differently. Not all liver masses require surgical resection. Although the patient initially presented to medical attention with abdominal pain, this pain was located in the right lower abdominal quadrant (not the right upper quadrant which is the expected location of pain originating from a mass in the liver). Additionally, her pain resolved without intervention; thus, the liver mass identified on CT scan was an incidental finding. There is no indication that she is symptomatic from the liver mass.

The liver resection is not currently medically necessary for this patient's incidentally identified, asymptomatic liver mass. Additional work-up to determine the diagnosis and its appropriate management is warranted.