Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain And Swelling
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female who presented to the emergency department (ED) with worsening abdominal pain, distention, generalized anasarca and bilateral lower extremity edema. She has a history of alcoholic cirrhosis, portal hypertension, ascites, congestive heart failure, seizure disorder and neuropathy. She was scheduled to have her paracentesis done as outpatient but could not wait until the day of her appointment due to worsening abdominal distention.

In the emergency department (ED), the patient was ill appearing and icterus, but was hemodynamically stable. She was given intravenous (IV) morphine and Tylenol for pain control. She was admitted to the hospital and started on intravenous (IV) Lasix. Her complete blood count (CBC) revealed a white blood cell (WBC) count of 9.22, and a hemoglobin/hematocrit (Hb/HCT) of 7.9/24.  The patient's chem-panel was remarkable for mild hyponatremia with sodium (Na) at 133, normal potassium (K), and blood urea nitrogen (BUN) 36 / creatinine 1.52.  The liver function tests were normal except for mildly elevated alkaline phosphatase of 220. The prothrombin time (PT) / international normalized ration (INR) were 13.6/1.5.  

The patient underwent diagnostic paracentesis and was started on intravenous (IV) antibiotics. Her ascitic fluid was negative for spontaneous bacterial peritonitis. The following day, the patient underwent large volume paracentesis and three liters of fluid removed. Her abdominal pain was controlled with Oxycodone. The gastroenterology (GI) and cardiology consults were requested for the management of ascites and congestive heart failure (CHF). The patient was continued on intravenous (IV) Lasix and she was discharged home the following day on a higher dose of diuretics to prevent rapid accumulation of ascites and lower extremity edema. She was advised to follow up with her primary care physician (PCP) and gastroenterologist (GI) as an outpatient.

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

The patient has a long-standing history of alcoholic cirrhosis and ascites requiring frequent large volume paracentesis. She was admitted with abdominal distention and pain secondary to large ascites, and lower extremity edema. On admission, the patient was hemodynamically stable and afebrile. She underwent large volume paracentesis, after her abdominal pain improved. Her ascites was managed with intravenous (IV) Lasix for two days after which her lower extremities edema and generalized anasarca improved, and she was discharged home on a higher dose of diuretics.  Based upon this clinical course, she could have been safely managed at the lower level of care.  The patient was hemodynamically stable and afebrile.  In a stable patient, large volume paracentesis can be done in a lower level setting.  The patient underwent large volume paracentesis without any hemodynamic compromise.  Her ascitic fluid was negative for spontaneous bacterial peritonitis.  Therefore, this patient could have safely and appropriately been managed at the lower level of care.