Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal-Gastrointestinal Bleeding
Treatment: Inpatient hospital stay
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has overturned in whole the denial.

The patient has a medical history of carcinoid tumor status post small bowel resection, dual antiplatelet therapy with aspirin and Plavix, hypertension, hyperlipidemia, coronary artery disease status post myocardial infarction and stent placement x3, iron-deficiency anemia, hemorrhoids, and anal fissure. The patient presented to the emergency department  seven days after surgery, with diarrhea and hematochezia. The patient had ongoing bowel movements with bright red blood in the emergency department. Vital signs were unremarkable. Physical examination was notable for clean, dry, intact incision sites, and a small left lateral external hemorrhoid and posterior anal fissure without active bleeding. Electrocardiogram showed sinus rhythm with T wave inversions similar to prior findings. Labs showed a low hemoglobin of 11.1 g/dL. Chest x-ray showed no focal consolidation, pleural effusion, or pneumothorax. The patient was treated with intravenous fluids. Aspirin and Plavix were held. The following day the patient felt fatigued after having to use the bathroom multiple times, and felt dizzy and unstable when walking; the patient reported dark tarry bowel movements with some bright red blood. Labs showed a low hemoglobin of 9.2 g/dL and hematocrit of 29.6%. On the day after, the patient felt better, but melena persisted. Labs showed a low hemoglobin of 7.8 g/dL and hematocrit of 23.7%. Gastroenterology consultation concluded that the patient had anastomotic versus diverticular bleeding, less suspicious of upper gastrointestinal bleeding; recommendation was to continue clear liquids, monitor hemoglobin, and consider endoscopy and colonoscopy if bleeding continues. Cardiology consultation recommended restarting aspirin when no bleeding contraindications, and continuation of Crestor and Zetia. On the day after that, the patient denied further melena or hematochezia. Labs showed low hemoglobin of 7.7 g/dL and hematocrit of 23.8%. Aspirin was restarted. On the day of discharge there were no further bowel movements. Labs showed low hemoglobin of 8.2 g/dL and hematocrit of 25.5%. The patient was discharged on low-dose aspirin and off Plavix. 

The inpatient hospital admission was medically necessary as the inpatient level of care is supported in this case. The patient had recently undergone resection of a tumor including small bowel resection; there was concern for anastomotic bleeding [1,2]. As the patient was taking dual antiplatelet therapy, there was a risk for rapid decompensation [1-4]. The patient had ongoing clinical gastrointestinal bleeding corroborated by a large drop in hemoglobin on labs. Cardiology recommended the resumption of aspirin and appropriately recommended monitoring in the hospital for an additional day to assess for onset of rebleeding. For these reasons, the inpatient level of care is supported for the entire stay in this case.
Additionally, the patient met Milliman Care Guidelines for "Gastrointestinal Bleeding, Lower", for inpatient level of care. The patient had ongoing active bleeding per rectum (e.g., decreasing hematocrit, recurrent hematochezia).