Diagnosis: Abdominal swelling
Issue under review: Inpatient admission
The health plan denied Inpatient admission.

Determination:
The health plan's denial is upheld.

The patient is an adult male. The patient has a history of congestive heart failure, ascites as a result of liver cirrhosis, asthma, alcohol dependence, and polysubstance abuse. The patient has had multiple prior admissions to the hospital for provision of a paracentesis. The patient presented with increasing shortness of breath and dyspnea as a result of abdominal swelling. He also had pedal edema, low blood pressure, tachycardia, and hypothermia with a sodium of 120. The patient had tenderness of the abdomen, raising suspicion of spontaneous bacterial peritonitis. The patient was admitted and underwent a paracentesis, and he was then discharged when deemed stable.

The performance of repetitive large volume paracentesis for end stage cirrhotics does not require a full hospital admission. The patient did not evidence a fever, and spontaneous bacterial peritonitis can be ruled out by the analysis of the peritoneal fluids once removed. The patient had end stage cirrhosis, so a low sodium is baseline for the patient, as were his other findings and complaints, including a lower blood pressure. There was no cogent need for a full medical admission, as the entirety of the care as provided could have been rendered at a lower level of care.