Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was upheld.

This is a female patient with a history of hypertension (HTN), cerebral thrombosis, syncope and autoimmune hepatitis.  She presented to the Emergency Department (ED) with complaints of right lower quadrant (RLQ) abdominal pain. She reported having a liver biopsy one week ago and that she started having abdominal pain yesterday. Her presenting vital signs were: heart rate (HR) of 82, blood pressure (BP) of 123/73, afebrile.  Her abdomen was soft, non-distended with no rebound or guarding; she denied vomiting, or fever or chills. There was RUQ and right flank tenderness.  Labs revealed a hematocrit (Hct) of 36.7 with normal bilirubin and AST of 456 and ALT of 416.  A computed tomography (CT) of the abdomen was performed that showed trace hemorrhage adjacent to the inferior liver tip with no evidence of extravasation.  There was no acute intra-abdominal or pelvic inflammatory process. Gastroenterology was consulted and noted the plan to admit to the hospitalist service for pain control and monitor liver function test (LFT) and hemoglobin/hematocrit (H/H).  Surgery was called in consultation and recommended hepatobiliary iminodiacetic acid (HIDA) scan. She was made nothing by mouth (NPO) and received intravenous (IV) fluids and IV antibiotics. HIDA scan was done which ruled out bile leak. After a period of medical stability the patient was discharge home.

According to MCG Health General Recovery Care 24th Edition General Admission Criteria GRG: CG-GAC (ISC GRG) admission is indicated for 1 or more of the following: Hemodynamic instability; Hypertension requiring inpatient treatment; Acute cardiac or peripheral ischemia; Cardiac arrhythmias of immediate concern;  Severe heart failure; Respiratory abnormalities; Severe airflow or ventilation abnormalities; Impending or actual respiratory arrest; Neurologic abnormalities; New-onset severe neurologic findings; Suspected acute intra-abdominal process; Severe physiologic disorder; Abdominal abnormalities; Acute renal failure; Significant uremic complications; High fever or other high-risk infection situation; Temperature less than 95 degrees F (35 degrees C) (rectal); Severe electrolyte abnormalities requiring inpatient care; Acute blood loss causing significant abnormality; Severe anemia; High-risk low platelet count; Disseminated intravascular coagulation; Severe adverse drug or systemic toxin reaction requiring inpatient treatment; Severe pain requiring acute inpatient management; Severe malnutrition; Severe behavioral health issues; Inpatient monitoring needed; Treatment requiring inpatient care; Emergency procedures needed.  

As per MCG Health Inpatient and surgical care 24th edition Liver Disease Complications ORG:M- 570 (ISC) admission is indicated for 1 or more of the following: Hepatic encephalopathy that is moderate to severe or insufficiently responsive to observation care treatment; hemodynamic instability; Tachypnea (e.g. due to ascites) that persists despite emergency department and observation care treatment; Spontaneous bacterial peritonitis (ascitic fluid polymorphonuclear cell count of 250 cells/mm3 (0.25 x109/L) or more); Suspected infected ascites; Prothrombin time of 20 seconds or more (or INR of 2 or more); Prothrombin time greater than 15 seconds (or INR greater than 1.5) accompanied by any degree of hepatic encephalopathy; alcoholic hepatitis requiring treatment;  Acute exacerbation of liver disease indicated by ALL of the following: Total serum bilirubin of 5 mg/dL (86 micromoles/L) or more, Elevation of prothrombin time to more than 50% above normal (or INR greater than 1.5); The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.