Diagnosis: Hepatic encephalopathy
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld


The patient presented with confusion and constipation. She had a history of cirrhosis with hepatic encephalopathy and high ammonia levels. She has required frequent paracentesis. The Model for End-Stage Liver Disease (MELD) score was 30. She was afebrile and the vital signs were stable. There was no abdominal tenderness. A paracentesis was performed, and 4.7 liters of fluid were removed. There were no signs of infected ascites or spontaneous bacterial peritonitis (SBP). The encephalopathy was treated with lactulose and rifaximin. She was transferred to another hospital for evaluation for liver transplantation.

Milliman Care Guidelines (MCG) Clinical indications for admission for Liver Disease Complications (MCG M-570) include having hepatic encephalopathy as indicated by hemodynamic instability, tachypnea that persists after observation care, and spontaneous bacterial peritonitis. The patient had hepatic encephalopathy but did not have the other indications that are listed for admission. She also did not have infected ascites. She had chronic ascites and chronic episodes of hepatic encephalopathy. She did not have hepatorenal syndrome. The computed tomography (CT) scan did not show hepatocellular carcinoma or a portal vein thrombosis.

This patient had deteriorating cirrhosis and a rising MELD score. She required treatment with lactulose and rifaximin and then a transfer for evaluation for a liver transplant. The treatment for encephalopathy could have been given in the emergency room (ER) with observation status prior to being transferred. She did not meet MCG criteria for admission for Liver Disease Complications.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for inpatient hospital admission is not substantiated.