Diagnosis: Digestive System/Gastrointestinal-abdominal pain.
Treatment: Inpatient hospital stay.

The health plan denied the inpatient stay.
The reviewer has upheld in whole the health plan's determination.

This is a patient with a history of idiopathic thrombocytopenic purpura (ITP), who presented to the emergency department (ED) due to abnormal liver function tests. The patient was complaining of some mild epigastric and right flank pain for several weeks intermittently. She also had mild nausea but no diarrhea, dysuria, or hematuria. Home medications include Atarax, omeprazole, and Promacta for ITP. Per the ED assessment, the patient has elevated liver function tests (LFTs), a known adverse reaction of Promacta. Due to right upper quadrant discomfort, they obtained a right upper quadrant ultrasound, gastrointestinal (GI) consultation, and a rescreen for hepatitis. A computed tomography (CT) scan of the abdomen and pelvis showed no acute disease. The right upper quadrant ultrasound showed gallbladder sludge and tiny stones without cholecystitis or biliary dilation. The LFTs improved as well. The gastroenterologist assessed the patient. Promacta was stopped on admission. A hematology consultation was obtained, who agreed with the current work-up. Overnight, asymptomatic bradycardia was noted, and a 2D echocardiogram showed no significant findings. Thyroid function tests were normal. The patient had been taking between 4 and 8 Tylenol per day, four times per week, which made them concerned about Tylenol toxicity and initiated the patient on Mucomyst.
Inpatient stay is not medically necessary for this patient. The patient was admitted for elevated liver enzymes and nonspecific abdominal discomfort. Acute cholecystitis and choledocholithiasis were ruled out. The lab abnormalities were attributed to Promacta. The patient did not have refractory ITP, as the platelet counts remained in the 360,000 range, significantly higher than any concerning thrombocytopenia level. It was quickly determined by both hematology and gastroenterology that Promacta is the culprit and should be discontinued, the elevation of liver enzymes more than three times the baseline range. Determination to stop this medication was made within 24 hours of hospitalization. Regarding the bradycardia the patient was asymptomatic. The echocardiogram was completely normal, and thyroid function tests were also unremarkable. The rest of the work-up performed in the hospital can be accomplished under a lower level of care and does not necessitate inpatient admission. The patient has no evidence of hepatic encephalopathy, spontaneous bacterial peritonitis or ascites, significant coagulopathy, elevated prothrombin times, or international normalized ratio (INR); no history of alcoholic hepatitis. There is no evidence of hepatorenal syndrome or hepatic vein occlusion. Evaluation in the hospital failed to reveal serious causes of nausea and vomiting, such as bowel obstruction, acute cholecystitis, acute pancreatitis, ileus, or intraabdominal infection.