Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hepatitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a medical history of polysubstance abuse including intravenous drug abuse on methadone. She presented to the emergency department with hematemesis for one day, diffuse burning abdominal pain, dark urine, and clay-colored stools with streaks of blood. She had left against medical advice after a diagnosis of acute hepatitis, and used heroin as recently as that day.
Her vital signs were notable for a blood pressure of 98/65 millimeters of mercury (mmHg). The physical examination was notable for a soft, nontender abdomen. Lab results showed an unremarkable complete blood count and elevated aspartate aminotransferase of 1,640 units per liter (U/L), elevated alanine aminotransferase of 2,083 U/L, elevated alkaline phosphatase of 151 U/L, and elevated bilirubin of 7.0 milligrams per deciliter (mg/dL) with a direct bilirubin of 5.9 mg/dL. A urinalysis was positive for bilirubin, ketones, protein, and leukocytes. A urine toxicology screen was positive for opiates, methadone, benzodiazepines, and marijuana.
A computed tomography scan of the abdomen and pelvis showed dilated intrahepatic ducts, hepatomegaly, pericholecystic fluid, normal spleen size, and moderate stool in the colon. Lab results showed an elevated aspartate aminotransferase of 1,366 U/L, elevated alanine aminotransferase of 1,829 U/L, elevated alkaline phosphatase of 136 U/L, and elevated bilirubin of 5.0 milligrams per deciliter (mg/dL). The alpha-fetoprotein was elevated at 8.5 nanograms per milliliter (ng/mL) and the hepatitis C viral load was 85,000 international units per milliliter (IU/mL). An Infectious Disease consultation concluded that she had an acute liver injury and recent diagnosis of hepatitis C, transaminases trending down, and recommended outpatient Gastroenterology and Infectious Disease follow-up for management of hepatitis C. A gastroenterology consultation concluded she had elevated transaminases secondary to acute viral hepatitis, and recommended daily labs, intravenous hydration, avoid hepatotoxins, serologic work-up for viral hepatitis and autoimmune hepatitis, and magnetic resonance cholangiopancreatography to evaluate intrahepatic ducts as biliary dilation could be due to effect of methadone. She was discharged.
At issue is the medical necessity for the inpatient level of care.

The inpatient level of care is not medically necessary.
The patient had hepatitis, but was not assessed to have decompensated liver function; workup was recommended with imaging and labs, but no further intervention was recommended (other than outpatient evaluation and therapy), and there were no complications such as variceal bleeding, severe hepatic encephalopathy, or acute liver failure which would warrant the inpatient level of care [1-4]. Her Model for End-Stage Liver Disease (MELD) score was 14 and Maddrey's discriminant function was 6 points; evidence for decompensated liver disease and alcoholic hepatitis were lacking [1-3]. She reported gastrointestinal bleeding, but there was no hypotension, hemodynamic instability, sharp drop in hemoglobin, or visible ongoing gastrointestinal bleeding [5-7]. Based on the available information, the care which was undertaken, including observation, monitoring, labs, and specialist consultations, with plan for labs and imaging, could have been performed without the inpatient level of care.