Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is overturned in part.

The patient is a female with a past medical history significant for recent cystectomy, who was admitted to the hospital with worsening abdominal distension, ascites, hepatosplenomegaly, and increased bilirubin levels.
The patient reported some mild epigastric discomfort but denied nausea, vomiting. When the patient was seen by the admitting physician, she was already kept nothing by mouth (NPO) for an upcoming liver biopsy performed by interventional radiology. The review of systems was negative for shortness of breath, chest pain, dizziness, or lightheadedness.
When seen by the admitting physician, the patient was afebrile. The heart rate was 104 beats per minute (bpm), respiratory rate 19 breaths/minute, blood pressure 128/86, oxygen saturation 100%.
 
In the hospital, the patient was seen by a gastroenterologist who confirmed the diagnosis of obstructive intrahepatic jaundice. The gastroenterologist stated that the patient previously was diagnosed with non-alcoholic steatohepatitis (NASH) years ago but received no treatment for this. The gastroenterologist recommended waiting for the liver biopsy results.
Subsequently, the patient underwent paracentesis, and approximately 5 liters (L) of fluid was removed.
The patient's clinical condition gradually improved, including a decrease in abdominal pain and improvement in appetite.
Therefore, the patient was transitioned to oral pain medications and discharged from the hospital.

The health plan's determination is overturned in part. 

The patient had an acute exacerbation of chronic liver disease with a significant increase in the total bilirubin, presence of ascites, and coagulopathy. The patient reported significant weight loss, diminished oral intake, increasing abdominal girth. Reportedly, 5 liters (L) of fluid was removed during the paracentesis.
Taking into consideration the severity of the patient's condition, the acute inpatient hospital stay was indicated in part.
This coincides with Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 24th Edition criteria for complications of liver disease.
Based on the criteria, admission at the acute inpatient level of care is required for patients with acute exacerbation of chronic liver disease in association with total bilirubin greater than 5, the elevation of international normalized ratio (INR) greater than 1.5, and also the presence of ascites. In this clinical case, the patient fulfilled these criteria.
Having said that, the patient did not require admission at the acute inpatient level of care for the entire stay. According to the medical records, the patient's clinical condition improved. At that time, the patient was already switched to oral pain medications, and also was started on Lasix. She ambulated and tolerated her diet. She passed flatus and was voiding without difficulties.
By that time, the patient already had a liver biopsy performed.
Reportedly, for several days it was mentioned in the progress notes that the patient was going to have paracentesis. It was unclear why this procedure was delayed. Finally, the paracentesis was performed. There was no evidence of spontaneous bacterial peritonitis. The patient's clinical condition gradually improved, and she was discharged.
Therefore, the inpatient admission was medically necessary in part. The first four days were medically necessary at the inpatient level of care. The last four days were not medically necessary at the inpatient level of care and could have been managed at a lower level of care status.