Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Liver Cirrhosis. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is a man with a history of liver cirrhosis secondary to non- alcoholic fatty liver disease. He had been recently added to the liver transplant list. He also has history of portal hypertension, esophageal variceal bleeding status post banding, morbid obesity status post gastric bypass, hypertension, and anemia.  He presented to the Emergency Department (ED) for an emergency evaluation due to acute altered mental status with worsening confusion. 

The patient was tachycardic (pulse of 104 beats per minute) and hypotensive (blood pressure of 97/62 mmHg [millimeters of mercury]). He was noted to have altered mental status. In the emergency department, nasogastric tube was placed and the patient was administered lactulose.  Labs showed acute kidney injury, elevated BUN (blood urea nitrogen) of 29 mg/dI (milligrams per deciliter), elevated creatinine of 1.5 mg/dI (milligrams per deciliter) (compared to baseline creatinine 1 mg/dI [milligrams per deciliter]), and lactic acidosis, with lactate level of 2.6 mmol/L (millimoles per liter). 

On day two, the patient was in the floor, and the laxis was reduced from BID (twice daily) to QD (daily). Hydration was given, the patient noted to improve his mental status.

On day three, the patient's confusion resolved. Creatinine and blood urea nitrogen trended down after dose modification. The patient was discharged.

Yes, the Inpatient admission was medically necessary.
The patient suffered from worsening mental status (encephalopathy), secondary to acute kidney injury, secondary to dehydration (evident by lactic acidosis, tachycardia, hypotension). The primary medical need for admission is acute kidney injury.

Per the European Association for the Study of the Liver detailed the diagnosis (EASL), management and prognosis of acute kidney injury (AKI) in decompensated cirrhosis, "In patients with cirrhosis the diagnosis of AKI [acute kidney injury] should be based on adapted KDIGO [Kidney Disease Improving Global Outcomes] criteria, thus, either on an increase in SCr [serum creatinine] of > [greater than] 0.3 mg/dl [milligrams per deciliter] from baseline within 48 h [hours], or an increase of 50% from baseline within three months." Furthermore, "In patients with decompensated cirrhosis, AKI [acute kidney injury] has a negative impact on hospital survival according to either the initial stage, or the peak stage." (1)

Of note, the American Association of the study of the liver disease (AASLD) usually endorses the EASL (European Association for the Study of the Liver) guidelines and have combined guidelines for various liver conditions. EASL (European Association for the Study of the Liver) guidelines are considered the standard of care across the USA.

A landmark study by Wong et al 2013, evaluated the influence of acute kidney injury among patients with decompensated cirrhosis. It found higher percentages of patients with AKI (acute kidney injury) died within 30 days of hospitalization (34% vs 7%), were transferred to the intensive care unit (46% vs 20%), required ventilation (27% vs 6%), or went into shock (31% vs 8%); patients with AKI (acute kidney injury) also had longer stays in the hospital). (2)

Thus, the admission in the acute care setting is crucial for management of acute renal injury among decompensated cirrhosis due to the gravity of the prognosis.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient, as the admission was medically necessary.
The admission in the acute care setting is crucial for management of acute renal injury among decompensated cirrhosis due to the gravity of the prognosis.