Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Hospital Admission. 
The denial is upheld. 

This is a male admitted for a diagnosis of anasarca. The patient had a history of cirrhosis secondary to hepatitis C virus who presented with a four-day history of scrotal and bilateral swelling. His vital signs demonstrated a blood-pressure at 136/75, pulse was 72, temperature was 97.8F, respiratory rate was 18 and oxygen (O2) saturation was 100%. The physical exam showed no acute distress or altered mental status. There was one plus edema below the knee and trace bilateral edema in the thighs. His international normalized ratio (INR) was 1.3 with platelets 113,000 and hemoglobin at 8.5. Sodium was 138 with a creatinine at 0.79. The urine drug screen was positive for tetrahydrocannabinol (THC), cocaine, methadone, and opiates. An electrocardiogram (EKG) showed a normal sinus rhythm. An ultrasound of the abdomen showed mild abdominal ascites. An ultrasound of the scrotum showed small bilateral hydrocele's with diffuse edema of the scrotal wall. A chest x-ray showed gynecomastia. The duplex of the lower extremities was negative for deep vein thrombosis.
The patient was treated with intravenous Lasix which relieved the edema. Gastroenterology evaluated the patient and recommended a computed tomography (CT) scan of the abdomen and pelvis with a plan to follow up as outpatient. The patient then left against medical advice.

At issue is the medical necessity of Inpatient Hospital Admission.

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

The requested health service/treatment of Inpatient Hospital Admission was not medically necessary for this patient.

According to UpToDate, 2021, "How rapidly should edema fluid be removed? - When diuretics are administered, the fluid that is lost initially comes from the intravascular space. This results in a reduction in the venous pressure and consequently in capillary hydraulic pressure, thereby promoting partial restoration of the plasma volume by the mobilization of edema fluid into the vascular space.

The rapidity with which this occurs is variable. In patients with generalized edema due to heart failure, the nephrotic syndrome, or primary sodium retention, the edema fluid can be mobilized rapidly since most capillary beds are involved. Thus, in patients with anasarca, removal of 2 to 3 liters of edema fluid or more in 24 hours can usually be accomplished without a clinically significant reduction in plasma volume.

An important exception occurs in patients with cirrhosis and ascites but no peripheral edema [4,5]. In this setting, the excess ascitic fluid can only be mobilized via the peritoneal capillaries. Direct measurements have indicated that 300 to 500 mL/day is the maximum amount that can be mobilized by most patients with isolated ascites [4,5,8]. If the diuresis proceeds more rapidly, the ascitic fluid will be unable to completely replenish the plasma volume (figure 2), resulting in azotemia and possible precipitation of the hepatorenal syndrome. This limitation does not apply to patients with cirrhosis who also have peripheral edema, due to the rapid mobilization of the edema fluid into the vascular space." [1]

The patient in this case had volume overload from a history of cirrhosis but did not have heart failure, nephrotic syndrome, sodium retention, hemodynamic instability, or abnormal renal function. Gastroenterology evaluated the patient and recommended a CT scan of the abdomen and pelvis with outpatient follow-up. There is no evidence that the patient's needs could only be met at an inpatient level of care. 
Therefore, the requested health service/treatment of Inpatient Hospital Admission was not medically necessary.