Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain 
Treatment: Inpatient admission 

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

The patient is a male with past medical history (PMH) of hepatocellular carcinoma of the right lobe status post (s/p) resection done and has not followed up with Oncologist since then, hepatitis C virus (HCV) treatment naive, hypertension, alcohol (ETOH) use, depression, anxiety, and opioid dependence (methadone). The patient presented to the emergency department (ED) with one week history of abdominal pain associated with non-bilious, non-bloody vomiting. The abdominal pain improved after eating and wakes up from sleep for a long time. He was also complaining of chest pain and cough for two to three weeks. There was no history of hematemesis, melena, or bright red blood per rectum. He was seen in the ED previously and computed tomography (CT) scan of the abdomen done at that time revealed a possible mass measuring 2.4 centimeters (cm) on the posterior segment of the right lobe of the liver. 

In the ED, the patient was hemodynamically stable and afebrile. He was made nothing by mouth (NPO), and was started on intravenous (IV) fluids, IV Morphine, Pepcid, Reglan, Zofran and Maalox, and he was continued on methadone. The patient was also started on an IV Ativan protocol for alcohol withdrawal, and Nifedin by mouth (PO) for high blood pressure. In the ED, the patient received two liters of ringer lactate and he was admitted to the hospital. His physical examination was essentially unremarkable with no abdominal tenderness, ascites, and normal bowel sounds, His labs revealed hemoglobin (Hb) 11.2, hematocrit (HCT) 33.9, normal white blood cell (WBC) count and platelets, and normal prothrombin time (PT) / international normalized ratio (INR). His chemistry panel revealed blood urea nitrogen (BUN) / creatinine 43/2.2, sodium (Na) 131, mild elevated aspartate aminotransferase (AST), normal alanine aminotransferase (ALT) and normal Bilirubin and alkaline phosphatase. 

The next day, the patient's renal functions improved and his creatinine was 1.4 and BUN was 22. His abdominal pain was better and he was tolerating diet and no recurrence of vomiting. The Gastroenterology (GI) consult was done and triple phase CT scan of the abdomen and AFP were recommended, and the patient was advised to follow up in the liver clinic as an outpatient. He was continued on IV fluids and CT scan of the abdomen was ordered.The patient left the hospital against medical advice (AMA). His discharge medications were methadone, folic acid and multivitamins. 

No, the proposed acute level inpatient care was not medically necessary for the management of this patient's condition. 

The patient has a history of chronic hepatitis C, history of liver cancer for which he underwent resection, history of chronic alcohol abuse, and history of recurrence of liver cancer. He presented to the hospital with one week history of abdominal pain, nausea and vomiting, poor oral intake, weight loss, and was found to be have acute kidney injury secondary to dehydration. He was started on IV fluids to treat his acute kidney injury which resolved with appropriate hydration with IV fluids. His abdominal pain was treated symptomatically with IV Pepcid and morphine next day, he was able to tolerated diet and he had no recurrence of vomiting. He was evaluated by GI and CT scan of the abdomen was ordered but the patient left AMA. Given this clinical scenario, the acute level inpatient care was not medically necessary and he could have been safely and appropriately managed under lower level of care.