Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Jaundice
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

This is a patient with a history of hypertension, hyperlipidemia, diabetes mellitus, and hyperthyroidism.

The patient had presented to the emergency room reporting yellowing of the skin. She was admitted to the hospital the same day. She received diagnostic testing, laboratory work, intravenous fluids, intravenous famotidine, and a surgery. She had a gastroenterology and endocrinology consultation. A biopsy of a pancreatic mass was taken. The patient was discharged home. The plan noted that their criteria consider a full hospital admission for liver disease necessary when there are severe problems. These might include infection, confusion, or liver failure. The patient had none of these findings.

The appeal letter noted that there was a concern for acute jaundice, pancreatic head mass, obstructive transaminitis, intra and extrahepatic mass, and lactic acidosis.

The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient, as the inpatient admission is not considered medically necessary for this patient.

An inpatient admission is not considered medically necessary for this patient.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had new onset jaundice with a pancreatic mass noted and biopsied; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. As such the care could have been rendered at a lesser level.

While Fargo et al. and also Gondal et al. review the steps in evaluating a patient with new onset jaundice, there is no mandate for a full acute admission.
"Jaundice in adults can be an indicator of significant underlying disease. It is caused by elevated serum bilirubin levels in the unconjugated or conjugated form. The evaluation of jaundice relies on the history and physical examination. The initial laboratory evaluation should include fractionated bilirubin, a complete blood count, alanine transaminase, aspartate transaminase, alkaline phosphatase, glutamyltransferase, prothrombin time and/or international normalized ratio, albumin, and protein. Imaging with ultrasonography or computed tomography can differentiate between extrahepatic obstructive and intrahepatic parenchymal disorders. Ultrasonography is the least invasive and least expensive imaging method. A more extensive evaluation may include additional cancer screening, biliary imaging, autoimmune antibody assays, and liver biopsy. Unconjugated hyperbilirubinemia occurs with increased bilirubin production caused by red blood cell destruction, such as hemolytic disorders, and disorders of impaired bilirubin conjugation, such as Gilbert syndrome. Conjugated hyperbilirubinemia occurs in disorders of hepatocellular damage, such as viral and alcoholic hepatitis, and cholestatic disorders, such as choledocholithiasis and neoplastic obstruction of the biliary tree." (Fargo, M. V. et al. 2017).

"Careful selection of admission status by educated providers and a system to identify relevant cases for status changes can increase appropriate status assignment and, potentially, positively affect the economic burden placed on patients and hospitals." (Fulchiero, R. et al. 2020).

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