Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is upheld in whole. 

The patient is a female with a past medical history significant for liver cirrhosis, alcoholic hepatitis, seizure, chronic kidney disease stage III, hypertension, and irritable bowel syndrome (IBS) who presented to the emergency department with worsening weakness and falls at home. The patient was seen by her primary care physician who noted that she had an altered mental status and referred the patient to the emergency department for further evaluation. 

The review of systems was positive for fatigue but negative for fever or chills. The patient had abdominal distention and pain. The review of systems was positive for dizziness, weakness, and lightheadedness, as well as a dysphoric mood and sleep disturbance. The patient was in no acute distress. She looked chronically ill. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The patient had a regular rate and rhythm, without murmurs, rubs, or gallops. There was abdominal tenderness to palpation, but no guarding or rebound. On the neurological exam, the patient had slightly diminished muscle strength in the upper and lower extremities. She had delayed speech, although her thought process was normal. 

The patient was admitted to the hospital with generalized weakness and frequent falls, alcoholic liver disease, and hyperbilirubinemia, chronic pancreatitis, gastroesophageal reflux disease (GERD), chronic kidney disease, seizure disorder, depression, and hypertension. 

Even though her serum ammonia levels were very low, the treatment with lactulose was initiated. The patient's clinical condition improved, and on the day of discharge, she was close to her baseline. 

At issue is the medical necessity of the Inpatient Stay. 

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

The requested health service/treatment of Inpatient Stay was not medically necessary for this patient. 
The patient presented to the hospital with altered mental status, generalized weakness, and frequent falls. Even though the concern was raised that the patient had altered mental status, this was not suggested by the physical exam. It was indicated in the history and physical (H&P) that the patient was alert, and oriented to person, place, and time. The statement was made that the patient's mental status was at baseline, although, she had slightly decreased muscle strength in the upper and lower extremities. It is unclear why the patient's speech was delayed. The laboratory evaluation did not reveal any significant abnormalities that would justify admission at the inpatient level of care. The imaging studies including chest x-ray, and a computed tomography (CT) scan of the head were not concerning. The liver ultrasound revealed morphologic changes consistent with previously diagnosed liver cirrhosis. The patient had moderate ascites and cholelithiasis without evidence of cholecystitis. It is unclear why the patient was started on Lactulose, considering her serum ammonia level was low.
Overall, the patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. 

Therefore, the requested health service/treatment of inpatient stay was not medically necessary.