Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hepatic Failure, C diff, Left arm pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is partially overturned.

The patient presented to the hospital with left arm pain. The patient had undergone left brachial artery stenting times (x) 3 at the site of anastomosis. She developed left arm pain and a cold sensation for several days preceding this presentation. She was evaluated by interventional radiology, who performed a computed tomography angiography (CTA) of the chest, abdomen, and pelvis, which showed no evidence of pseudoaneurysm and normal runoffs of the left hand. The interventional radiologist noted possible small hematomas at the access site, which could possibly be impinging the brachial nerve. They provided the patient with Tylenol, oral Dilaudid as needed, intravenous (IV) Dilaudid for a breakthrough, and consulted pain management to evaluate the patient. They resumed the patient's home medications, including immunosuppressive medications for a liver transplant, Prograf, CellCept, and prednisone. They also consulted the liver transplant team to follow the patient while in the hospital.
The chronic pain consultant assessed the patient and noted slightly elevated blood pressures in the 150s systolic, with respirations of 17 and a heart rate of 76-97. The patient's temperature was normal. The cardiopulmonary exam was unremarkable, and the patient was fully oriented. Laboratory studies revealed normal renal function and electrolytes. Alkaline phosphatase was slightly elevated at 173, with a total bilirubin of 1.3. The hemoglobin was 8.9. After the assessment, they recommended Tylenol, a lidocaine patch, gabapentin 100 milligrams (mg) 3 times daily, duloxetine, and as needed tizanidine as well as nonsteroidal anti-inflammatory drugs (NSAIDs). They also recommended that neurology  evaluate the patient.
Neurology assessed the patient on the same day and performed a detailed exam. Recommendations included a nutritional workup for neuropathy and a magnetic resonance imaging (MRI) scan of the left upper extremity brachial plexus.
The patient remained in the hospital and was reassessed by a chronic pain consultant, who notes decreasing the blood pressure in the 90s, heart rates were improved in the 70s, and stable respirations and temperatures. The treatment plan was unchanged. The MRI report of the brachial plexus showed no abnormality. The interventional radiology team planned a discharge on this day; however, a rapid response team was called because the patient developed dizziness, chest pain, shortness of breath, and nausea. An electrocardiogram (EKG) was obtained, which showed normal sinus rhythm. A stat cardiac troponin was obtained, and it was negative. Cardiology was asked to see the patient and performed an echocardiogram, which showed stable cardiac findings. Based on the overall presentation, cardiac issues were excluded as a cause of the patient's symptoms.
The hepatology transplant team assumed care of the patient on this day. The patient had a history of pancreatic cancer status post-Whipple and has gone into fulminant hepatic failure due to Nash with liver transplant. The documented vital signs showed a stable blood pressures of 122/85 and 130/87, heart rate of 95, respirations of 18, and normal oxygen saturations. The physical exam described the patient as in no acute distress, well-developed, well-nourished with 1 plus (+) lower extremity edema, intact peripheral pulses, normal bowel sounds, clear lungs to auscultation, and regular heart rate and rhythm on the cardiac exam. They repeated the labs, which showed mild hyponatremia at 133, a creatinine of 1.47 up from 0.77, and relatively stable liver function tests (LFTs). The hemoglobin was 9, with a mean corpuscular volume (MCV) of 93.7. The hepatology team ordered a computed tomography (CT) venogram of the abdomen and upper extremities for bilateral lower extremity edema. The acute kidney injury (AKI) was attributed to a high Prograf level. They evaluated her immunosuppressive regimen, and noted mild leukopenia, and contemplated holding mycophenolate mofetil if the leukopenia worsened. The chronic pain consultant reassessed the patient again and noted stable vital signs. They recommended increasing gabapentin to 300 mg 3 times daily.
The patient was afebrile, with stable vital signs. The computed tomography (CT) venogram of the abdomen and legs was negative for an occlusion. There were no repeat creatinine levels on this day.
The patient remained in the hospital, and the creatinine had now improved to 1.33, the sodium was normal, potassium was normal, and the LFTs were similar to the previous labs. There were no documented changes to the treatment plan for the left arm pain or lower extremity edema. The patient was encouraged to get out of bed and ambulate. The chronic pain team signed off with no further recommendations.
The social worker met with the patient and discussed extending home care services with her family. The transplant team documented that the patient appears to have depression and therefore consulted psychiatry. The psychiatrist assessed the patient and documented that the patient's symptoms were inconsistent with major depression. They documented a diagnosis of possible delirium and recommended holding sedating medications like morphine, trazodone, or gabapentin if the patient continued to be somnolent.
The patient remained in the hospital, the plan was unchanged from the previous days, and there was no disposition documented. Physical therapy assessed the patient and recommended discharge to subacute rehabilitation (rehab) due to deconditioning.
The main intervention by the hepatology team was to lower the dose of CellCept to 500 mg twice daily.
Over the next two days, there were no significant changes in the progression of the patient's care, and the hepatology team was documenting awaiting insurance approval for acute rehabilitation. An MRI of the cervical spine was obtained, which did not demonstrate any pathology to explain the previously reported left arm pain. Serial labs appeared relatively stable. The patient was documented as eating well and awaiting placement during the following days.
The social worker documented that the patient was expressing resistance to going to rehabilitation and would like to go home. After extensive discussions with her husband, she changed her mind and agreed. The social worker documented that she placed a referral to acute rehabilitation.
Over the next two days, there were no significant changes in the vital signs, and lab results appeared relatively stable. The patient's hospital course remained the same, awaiting acute rehab placement. The pathology team reports this was denied, and they are in an appeal process. The patient felt constipated and was given MiraLAX. The physical therapy note from this day states vital signs are stable; the patient is alert and oriented times (x) 3. She ambulated a total of 130 feet, with seated breaks in between using a rolling walker.
Liver enzymes were fairly stable. Vital signs also remained stable, and the disposition was still in process, awaiting a decision appeal. The patient had loose stools, so the MiraLAX was stopped.
Diarrhea persisted, so Clostridium (C) difficile testing was requested. The patient was noted to be tachycardic intermittently. She was treated with intravenous (IV) albumin, and Lasix was stopped. The patient was given a dose of Neupogen to improve her leukopenia, and the white blood cell count improved to 7. The creatinine was at a baseline of 0.83.
The transplant team documented that the diarrhea was due to C. difficile, and the patient was transferred to a private room. They consulted infectious disease to evaluate her and recommend treatment for C. difficile. The infectious disease specialist recommended oral vancomycin. Disposition was to subacute rehab, pending C. difficile management now. The patient remained afebrile and continued to have loose bowel movements as expected with only 24 hours of treatment. The vital signs remained relatively stable, with mild tachycardia intermittently. The electrolytes and renal function appeared to be stable on this day. The vancomycin treatment was completed. The stool output slowly improved over this timeframe. On the 10th day of treatment with vancomycin, the patient was noted to have three bowel movements, and the transplant service ordered retesting for C. difficile. The progress note suggests the symptoms could be related to a noninfectious etiology.
The patient complained of leg pain, which prompted a lower extremity duplex study to rule out deep vein thrombosis (DVT). 
The lower extremity duplex scan was noted to be negative. The medical team documented a slow-to-the-ground fall, from the knees buckling, without trauma occurring in the room. X-rays of the knees were negative for a fracture.
Over the next two days, the patient's bowel movements were solid. However, the liver transplant team decided to restart oral vancomycin to taper and increase the Creon dose. The patient also complained of left deltoid tenderness to palpation, which was treated with warm compresses. The medical team continued to document a plan to discharge to subacute rehab soon.
The transplant team documented a plan for seven more days of vancomycin, and if no improvement, to switch to Fidoxamicin. They also ordered a cytomegalovirus (CMV) deoxyribonucleic acid (DNA) polymerase chain reaction (PCR). Loose stools were described as greasy, which was suggestive of pancreatic insufficiency. The patient was instructed to use Creon also with snacks, but she refused to do so.
Over the next two days, the CMV PCR came back negative. The rest of the treatment remained unchanged. The patient was still in the hospital, and given her refusal to take an increased dose of Creon; gastroenterology was consulted for a colonoscopy. A colonoscopy prep was started, which the patient could not tolerate. The colonoscopy was completed with biopsies, which were not immediately available for review. The transplant infectious disease (ID) specialist recommended adenovirus PCR as well to be checked.
The oral vancomycin was discontinued, Creon was increased to 6 capsules with meals. The colonoscopy biopsies showed mildly active chronic colitis, possible inflammatory bowel disease (IBD). The patient was started on Pentasa 1 gram (g) 4 times daily. All of the other infectious studies came back negative. The patient was also started on three times daily Imodium. The patient did not tolerate Pentasa and was switched to mesalamine enemas by the next day.
A general gastroenterology consultation was requested, who concluded that the patient's symptoms were probably related to either microscopic colitis, unmasked by the discontinuation of prednisone. They also document that the patient had solid stool seen on the kidney ureter bladder (KUB) and to use Imodium sparingly. The social worker documented that referrals were sent to a discharge facility and that the husband was supposed to tour these facilities, but it is unclear if that was accomplished.
The dietitian documented that the patient has significant dietary indiscretions, with many fatty snacks, including chips, sausage, eggs, and cheese sandwiches.
The patient remained in the hospital. She was refusing mesalamine enemas. She was released home after a physical therapy assessment, deemed the patient stable for home. She was not restarted on the immunosuppressive regimen with CellCept.
At issue is whether the hospitalization was medically necessary at an inpatient level of care.

Based on the review of this hospitalization, for the first 4 days, care for this patient could be provided at a lower level of care. The patient presented with arm pain at the vascular access site, and it was reasonable to evaluate with imaging studies to ensure no injury. All of the studies were unremarkable. Therefore, there is no evidence of medical acuity to satisfy inpatient hospitalization.
However, for the remainder of the stay, clinical indications for admission to inpatient care are satisfied. This liver transplant patient developed an acute kidney injury, worsening lower extremity edema, some mild lactic acidosis, and leukopenia, requiring a higher level of care and subspecialty hepatology evaluation. Liver transplant patients are typically immunosuppressed, with a multitude of medications, which require close monitoring and adjustments. Acute kidney injury can be a symptom of liver rejection, and that would be a catastrophic outcome. Furthermore, the patient developed in-hospital complications of C. difficile enteritis, with subsequent worsening of malabsorption syndrome, electrolyte derangements. It was reasonable and medically indicated to continue to monitor the patient until stabilization occurred. Therefore, the treatment for this case exceeded lower level of care criteria during this time frame.