Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal/Other/Jaundice
Treatment: Inpatient Admission
The health plan denied the requested inpatient admission as not medically necessary. 
The health plan's determination is upheld.

The patient is a male with a medical history of hypertension, anxiety, and depression. He presented to the emergency department with jaundice, dark urine, fever, diaphoresis, fatigue, and malaise. Vital signs were unremarkable. Physical examination was notable for a soft, nontender abdomen with normal bowel sounds. Labs showed low white blood cell count of 3.3, a low potassium of 3.3, an elevated blood urea nitrogen of 19, an elevated creatinine of 1.4, an elevated aspartate aminotransferase of 414, an elevated alanine aminotransferase of 554, an elevated alkaline phosphatase of 270, and an elevated bilirubin of 4.7. A chest x-ray showed no radiographic evidence of an acute intrathoracic process. A computed tomography scan of the chest, abdomen, and pelvis with angiogram showed splenomegaly and enlarged periportal lymph nodes, and gynecomastia. An ultrasound of the abdomen showed hepatic steatosis, but otherwise was unremarkable. He was treated with intravenous fluids. He endorsed significant recent alcohol intake. Labs showed total white blood cell count of 3.7, a low hemoglobin of 11.8 and a hematocrit of 33, a low platelet count of 149, an elevated aspartate aminotransferase of 232, an elevated alanine aminotransferase of 393, an elevated alkaline phosphatase of 204, an elevated bilirubin of 2.4, a prothrombin time of 17.5 seconds, and an international normalized ratio of 1.44. An infectious disease consultation noted fever and diaphoresis for the last week with jaundice, elevated transaminases, and splenomegaly with periportal lymphadenopathy, and recommended serologic work-up for infection. The patient was reported to be stable, with no active complaints. Labs showed a low hemoglobin of 12.1 and a hematocrit of 34, an elevated aspartate aminotransferase of 181, an elevated alanine aminotransferase of 362 , an elevated alkaline phosphatase of 201, and an elevated bilirubin of 1.8. He was discharged  with a plan for primary care and gastroenterology follow-up.
At issue is the medical necessity for the inpatient level of care.

The health plan's determination of medical necessity is upheld, in whole.

No, the inpatient level of care is not supported, and the care provided could have been provided at an alternate level of care for the duration of the stay. 
In this case, the patient was assessed to have alcoholic hepatitis and improved with conservative therapy. [1-3] There was no acute alcohol intoxication or withdrawal, and no complications such as spontaneous bacterial peritonitis or sepsis which would warrant the intermediate level of care during the dates at issue. [4] Elevated liver enzymes gradually improved, and there was no evidence of biliary obstruction, biliary or pancreatic mass, bile leak, ascending cholangitis, hepatic abscess, or other complications which would require the inpatient level of care. [5,6] The actions performed, including labs, monitoring, infectious disease consultation, and antibiotic therapy could have performed without the inpatient level of care, at an alternate level of care.
Per the InterQual Acute Adult criteria for General Medical, the Acute level of care is supported based on gastrointestinal or biliary disorder with bilirubin > (greater than) 3.0 with abdominal pain, imaging, and intervention of intravenous fluids. However, as above, in this specific case the inpatient level of care is not supported by current medical literature or Milliman Care Guidelines for Liver Disease Complications.