Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is upheld

The medical records indicate the patient has a history of liver cirrhosis secondary to nonalcoholic steatohepatitis (NASH), ascites of liver, anemia, invasive ductal carcinoma of right breast and malignant neoplasm of axilla and breast. She presented to the emergency room (ER) with complaints of abdominal pain and nausea. Diagnostic results showed ascites, right pleural effusion with adjacent atelectasis, and a 4.8 centimeter (cm) right hepatic mass. The patient received blood transfusions for a hemoglobin of 4.8 and a platelet count of 70. She was admitted and the patient reported feeling better with abdominal issues resolved following bowel movements and then signed out against medical advice (AMA).

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. This was a patient with chronic problems related to cirrhosis and could have been followed as an outpatient after the transfusions. Platelet count, in fact, did not require a transfusion at a value of 70 and chronic hypersplenism. There was a positive (+) guaiac test but no active bleeding. 

The hospital admission is not considered medically necessary for this patient. This was a patient with chronic problems related to cirrhosis and could have been followed as an outpatient after the transfusions. The platelet count, in fact, did not require a transfusion at a value of 70 and chronic hypersplenism. There was a positive (+) guaiac test but not active bleeding. The emergency department (ED) could have dealt with optimizing the patient and then discharge for a follow up. As such, the hospital stay was not medically necessary.

"Cirrhosis is characterized by fibrosis and nodule formation of the liver secondary to chronic injury, leading to alteration of the normal lobular organization of the liver. Various insults can injure the liver, including viral infections, toxins, hereditary conditions, or autoimmune processes. With each injury, the liver forms scar tissue (fibrosis), initially without losing its function. After a chronic injury, most of the liver tissue becomes fibrotic, leading to loss of function and the development of cirrhosis." (Sharma B, John S. 2021).

"The mainstay of treatment is lifestyle modification with the goal to achieve at least 5% to 10% of weight loss. Both biochemical and histological improvement was seen in patients who had weight loss, which is accomplished via calorie reduction combined with exercise. One to two cups of caffeinated drip coffee may be considered as part of the lifestyle modification measure, given the reported association of caffeinated drip coffee with decreased liver fibrosis and decreased incidence of hepatocellular carcinoma. Studies have shown that eliminating high fructose corn syrup and increasing omega three fats in the diet is beneficial. Thiazolidinediones appear to be beneficial in improving adipocyte insulin sensitivity and preventing inappropriate lipolysis. Their side effect profile (weight gain, congestive heart failure exacerbation, and osteoporosis), however, limits their use. Antioxidants such as vitamin E are of modest benefit and likely safe in non-diabetic patients; a dose of 800 units per day may be offered in such patients after explaining the risks of increased all-cause mortality with high dose vitamin E therapy. In patients with diabetes, we do not recommend giving a dose higher than 400 units per day." (Sharma B, John S. 2022).                                                         

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the hospital admission is upheld. Medical Necessity is not substantiated.