Diagnosis: Liver disease, bilateral lower extremity edema.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

This is a female patient with alcoholism, obesity, and gastric bypass who presented to the emergency room for evaluation of abnormal labs with persistent bilateral lower extremity edema, worsening functional status, and frequent falls. The patient had an increase in alcohol intake for a few months and had been drinking 15 to 20 drinks per day. The patient had an overnight stay at another hospital and since then, she had experienced poor appetite, extreme weakness, inability to ambulate without assistance. The patient had seven falls due to weakness and unsteadiness. She had bilateral lower extremity edema for the last three months. In the emergency room, the patient had jaundice and scleral icterus. She had abdominal distention and ascites. Labs showed an alanine transaminase (ALT) of 31 and an aspartate transaminase (AST) of 92. Total bilirubin was 5.0. The patient was started on intravenous (IV) thiamine.

Magnetic resonance cholangiopancreatography (MRCP) was ordered but the patient refused. The patient was started on Lasix and lactulose three times per day. On day two, the patient reported persistent generalized weakness for several days. The patient denied abdominal pain or back pain. On day three, the patient reported persistent generalized weakness for several days. The edema improved mildly.

No, the proposed inpatient admission was not medically necessary.
The medical records do not support that the acute inpatient admission was medically necessary. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting.

A lower level of care would have been a more efficient setting, since the patient did not require any procedural or surgical intervention, did not require to be nothing by mouth for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications, did not have acute kidney injury, did not have electrolyte derangement needing intravenous replacement, did not have fevers, did not have an elevated white count, was not being considered for liver transplant, did not have acute gastrointestinal bleeding, did not have acute liver failure, and did not have any complications such as intra-abdominal abscess or a surgical abdomen.

Yes. the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.