Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcoholic liver disease.
Treatment: Liver transplant and inpatient admission.
The insurer denied the liver transplant and the inpatient admission.  The denial is overturned.
The proposed liver transplant and associated inpatient stay for this patient is medically necessary and appropriate.
The patient is a female with history of alcoholic cirrhosis, hypertension, and anxiety disorder, and presented to the hospital with progressive jaundice, ascites, hepatic encephalopathy, and renal dysfunction. She has bilirubin of 54, INR (international normalized ratio) 3.3, and Creatinine of 1.79, with a MELD (Model for End Stage Liver Disease) score of 38. She was initially treated with prednisone for superimposed acute alcoholic hepatitis for four days with no response. She had undergone two large volume paracenteses. 
The patient had started drinking heavily after her father's death. She underwent CT scan of the abdomen, which revealed LI-RADS (Liver Imaging Reporting and Data System) IV lesion (HCC [hepatocellular carcinoma] within Milan criteria versus regenerative nodule).
As per the multidisciplinary team assessment, the patient has history of active alcohol use disorder, depression and anxiety disorder, complicated bereavement (not treated). However, she has adequate social support system from her mother, who would live with her post-transplant, and also from her sister and son, who would be involved in the patient's post-transplant care in the event of proceeding with transplant at this point in time in view of her risk factors. 
The patient will also need health and mental health treatment post-transplant, as per the psychologist. The patient's insight into her alcohol use disorder (AUD) is fair and developing, and she agrees to engage in alcohol rehab, relapse prevention program and mental health treatment post-transplant. However, as per the clinical records, the transplant psych clearance is pending for listing for liver transplant. The Liver transplant committee, however, has a consensus that the patient should be listed for liver transplant, as with a high MELD score, the three-month mortality without transplant is 100%, and she is not in a position to undergo alcohol rehab prior to her transplant.
The patient has de-compensated alcoholic cirrhosis, refractory alcoholic hepatitis, and high MELD score with a three-month mortality of 100%. She does have active alcohol use disorder and mental health disorder and has not undergone alcohol rehab and mental health treatment in the past. Her alcohol abuse was triggered and worsened after the death of her father and brother and she never sought any support for her bereavement and depression. She resorted to heavy drinking to treat her depression and bereavement. 
Although concerns about the patient's risk factors were expressed by the SW (social worker) and psych, the agreement was reached by the Multi-D (multi-disciplinary) committee to proceed with the listing as the patient's family support is adequate in terms of her post-transplant care, adherence/compliance to mental health and alcohol treatment post-transplant. As long as there is a commitment of patient/family to sobriety and formalized agreement to adhere to lifelong total alcohol abstinence and established contract and participation in addiction rehabilitation following transplant, and presence of close, supportive family members or caregiver, and lastly a letter from the transplant Psychologist/SW that the patient is deemed an appropriate candidate for liver transplant given her high risk behavior, the patient should be listed for liver transplant. Six-month sobriety is no longer a prerequisite for listing for liver transplant for patients with end-stage liver disease secondary to heavy alcohol abuse.
In addition, the proposed associated inpatient stay is appropriate and medically necessary for the management of this patient's decompensated liver disease and complications.