Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal distension, rectal pain, and hemorrhoids
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male with co-morbid health conditions (cirrhosis, hepatic encephalopathy, esophageal varices, anemia, hypercholesterolemia, hypertension, chronic kidney disease, and obesity) who presented to the emergency department (ED) with worsening abdominal distension, rectal pain, and hemorrhoids. He was also being evaluated for liver transplantation.  He has previously been treated with variceal banding and with transjugular intrahepatic portosystemic shunt (TIPS).  

The patient's vital signs identified tachycardia at 108 beats per minute in the emergency department.  The patient's white blood cell (WBC) count was normal at 10 thousand (K), hemoglobin was low at 9.9, platelet count was normal at 224 thousand (K), albumin was low at 2.5 and bilirubin was elevated at 2.6.  Examination showed abdominal ascites, generalized tenderness, and an external hemorrhoid.  Hepatology and colorectal surgery consultations were completed and the patient was admitted to the hospital.  The patient was treated with intravenous fluids, steroid suppositories, and nonoperative treatment of the external hemorrhoids.  Topical lidocaine, sitz baths, and stool softeners were prescribed.  Spontaneous bacterial peritonitis was not clinically suspected.

Day two, the patient was treated with paracentesis (five liters of non-infected fluid was removed).  On day three, the patient was considered to be stable for discharge with planned outpatient follow up.

No, the proposed inpatient hospital admission was not medically necessary.

This patient presented to the emergency department (ED) with abdominal pain, distension and an external hemorrhoid.  These conditions were related to his chronic liver disease/cirrhosis.  Lab data and physical exam did not support acute deterioration of his known liver disease.  He was clinically and hemodynamically stable at the time of presentation.  He did not require acute surgical intervention and was treated symptomatically for the hemorrhoidal condition.  He did undergo paracentesis with drainage of five liters of non-infected ascitic fluid, though the records support that this could have been performed with an observation level of care.  The patient remained clinically stable and was discharged from the hospital.	

This patient could have most appropriately been treated in the observational setting during this period of time.  He was clinically stable at the time of presentation and remained so during the period of care.  Provision of paracentesis, including overnight observation, could have been provided with an observational level of care.  Inpatient level of care was not medically necessary in this case.

The health plan has acted with sound medical judgment in this case.  The records indicate that this patient presented with abdominal pain, distension and an external hemorrhoid.  These conditions were related to his chronic liver disease/cirrhosis.  Lab data and physical exam did not support acute deterioration of his known liver disease.  He was clinically and hemodynamically stable at the time of presentation.  He did not require acute surgical intervention and was treated symptomatically for the hemorrhoidal condition.  He did undergo paracentesis with drainage of five liters of non-infected ascitic fluid.

The records support that this patient was treated in a timely manner and within the accepted standard of care.  However, the care and treatment provided could have reasonably been rendered with an observation level of care.  The medical necessity of inpatient admission is not established.