Diagnosis: Liver Disease, Abdominal Pain, and Leg Swelling.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.
The denial is overturned.

This is a male with a past medical history alcohol (ETOH) abuse, cirrhosis, hepatic encephalopathy on lactulose and rifaximin, gastrointestinal bleed (GIB), and anemia requiring transfusions, who presented to the emergency department with abdominal distention and leg swelling. He has a history of alcohol induced cirrhosis.

The patient was admitted for anasarca, ascites, and anemia. His hemoglobin was 6.5. In the emergency department, the patient received intravenous Lasix. Day two, the plan was to do an esophagogastroduodenoscopy (EGD) after large volume paracentesis. The patient had paracentesis with removal of six liters of fluid. He was given albumin. He received one unit of packed red blood cells (pRBCs). On day three, the patient underwent esophagogastroduodenoscopy (EGD) which showed portal hypertensive gastropathy. He was given intravenous iron. He was treated with ciprofloxacin. He was evaluated for transjugular intrahepatic portosystemic shunt (TIPS) by hepatology but this was deferred. On day six, the patient had another paracentesis with removal of four liters. He had magnetic resonance image (MRI) of the liver which showed cirrhosis.

Yes, the proposed treatment was medically necessary.

Inpatient admission was medically necessary based on this patient's history of alcohol induced cirrhosis and underlying ascites (difficult to control) requiring intravenous Lasix and paracentesis times two. Additionally, the patient had anemia (severe, with hemoglobin of 6.5) requiring esophagogastroduodenoscopy (EGD) to rule out acute gastrointestinal bleeding and requiring a blood transfusion and intravenous iron. The patient required evaluation by Hepatology and was considered for the transjugular intrahepatic portosystemic shunt (TIPS) procedure.