Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Jaundice.
Treatment: Full Hospital Admission.

The insurer denied the Full Hospital Admission.  The denial is upheld.

The patient is a female with no significant past medical history who presented to the hospital with scleral icterus and jaundice. Outpatient testing revealed hyperbilirubinemia and elevated liver function tests (LFTs), after which she noticed yellowish discoloration of the sclera for one week. The patient reported nausea and vomiting for one day, generalized malaise, and darkened urine. She denies abdominal pain or diarrhea. She denied alcohol or Tylenol use; her only medication is an oral contraceptive.

Laboratory studies included a fairly normal complete blood count (CBC). The chemistry panel was unremarkable, with normal renal function. The LFTs show total bilirubin of 5.5, with a direct bilirubin portion of 4.3. Alanine aminotransferase (ALT) was 360, aspartate aminotransferase (AST) 244, alkaline phosphatase 292. Lipase was 73. An acute viral hepatitis panel and a stool polymerase chain reaction (PCR) for bacteria and viruses were ordered.

The patient was admitted to the medical floor with admitting diagnosis of elevated LFTs and acute hepatitis of unclear etiology. The medical team obtained an abdominal ultrasound which revealed a normal gallbladder; the liver was slightly enlarged. The computed tomography (CT) scan of the abdomen revealed mild periportal edema but no focal parenchymal abnormality of the liver. Coombs testing to rule out hemolytic anemia and an autoimmune panel for autoimmune hepatitis were also sent. Tylenol and alcohol levels were also ordered. Finally, a gastroenterology opinion was requested.

Gastrointestinal (GI) consultant recommended on 8/7/22 to discharge the patient from the hospital and establish for close outpatient follow-up. Outpatient magnetic resonance imaging (MRI) was scheduled. Most of the studies, including testing for Epstein-Barr virus, and flow cytometry, were still pending at the time of discharge. The patient was discharged to home.

The medical necessity for the full hospital admission is the subject under review.

The health plan's determination is upheld in whole.

The full hospital admission was not medically necessary for this patient. The patient had asymptomatic jaundice of undetermined clinical etiology. An extensive work-up was undertaken in the hospital. However, the patient had no evidence of acute liver failure. There was no evidence of acute hepatocellular injury by alcohol, excessive Tylenol use, or an infectious process. The imaging studies reveal no evidence of gallstones with choledocholithiasis, cholecystitis, liver abscess, or portal vein thrombosis. There was no history reported or toxicology to show alcohol toxicity of the liver in this patient. The patient was asymptomatic other than having scleral icterus and jaundice. There was no evidence of hepatic encephalopathy or hypotension that typically follows liver failure, ascites, or peritonitis. The laboratory studies did not reveal synthetic liver dysfunction, the most life-threatening aspect of acute liver injury. Chronic genetic conditions such as Gilbert syndrome can produce this type of abnormality in the young population. The patient had exposure to Epstein-Barr virus, which causes mononucleosis, which can produce this type of clinical picture. The patient was not dehydrated and did not have concurrent end-organ dysfunction.

In conclusion, given the lack of life-threatening vital sign instability, significant comorbidities, other organ dysfunction, and hyperbilirubinemia with jaundice, the patient could have been worked up at a lower level of care status. There is no indication for inpatient admission.