Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient has a past medical history significant for uterine fibrosis who was referred to the emergency department by her hematologist after an office visit, after the patient's laboratory evaluation revealed that her hemoglobin was 5. Reportedly, several days before the presentation, she had an appointment with a gynecologist for evaluation of uterine fibrosis with the discussion of possible myomectomy. At this office visit, the patient underwent blood work that showed that her hemoglobin was 4.9 and this was the reason she was referred to the hematologist.

At the time of the initial evaluation, the patient stated that she had been physically active, but over the course of 4 years had started to notice feeling increasingly weaker and lightheaded. She experienced shortness of breath during her workouts. This prompted the patient to decrease the time she spent working out. She also reported that over the course of 1 year her menses had been heavier, particularly during the first 2 days of the cycle. The patient stated that her symptoms, such as generalized weakness and lightheadedness, became worse after she had a coronavirus 2019 (COVID-19) infection. Otherwise, she recovered from the COVID-19 infection without significant complications.

The patient also stated that she had daily headaches which were triggered by bending over. The rest of the review of systems was negative. The patient denied fever, chills, chest pain, abdominal pain, nausea, vomiting, diarrhea, or any other complaints.

Upon initial evaluation she was afebrile, her heart rate was 68 beats per minute (bpm), blood pressure 110/74, respiratory rate 18 breaths/minute, and oxygen saturation 100% on room air.

The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), carotid bruits. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. The rest of the physical exam was unremarkable.

Laboratory evaluation revealed that her white blood cell count was 7.26, hemoglobin 5.4, hematocrit 20.5, and platelets 928. The sodium was 136, potassium 4.4, chloride 102, bicarbonate 23, blood urea nitrogen (BUN) 11, creatinine 0.76, and glucose 96. The international normalized ratio (INR) was 1.12.

After initial evaluation in the emergency department, the patient received 1 unit of packed red blood cells. She was seen by a gynecologist who recommended a transvaginal ultrasound, which the patient declined. She subsequently underwent a pelvic ultrasound. It demonstrated a hemorrhagic ovarian cyst on the right side. Further laboratory evaluation revealed that the patient had iron deficiency anemia. During the hospital stay, the patient received a total of 2 units of packed red blood cells as well as an iron transfusion.

In the hospital, the patient remained in satisfactory clinical condition and was discharged home with a recommendation to take iron supplements. At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.

The patient presented to the hospital with longstanding anemia. She had no acute symptoms that brought her to the hospital. During the hospital stay, the patient remained afebrile and hemodynamically stable. She had no signs of acute bleeding that required any intervention in the hospital. There was no evidence of active hemolysis. The anemia was not associated with recurrent syncopal episodes. There was no evidence that the anemia was associated with cardiac ischemia, peripheral ischemia, or arrhythmia of immediate concern.

Overall, the patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.

The hospital stay was very short and the care could have been provided at a lower level than inpatient.

This coincides with the Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 24th Edition Criteria for Iron Deficiency or Unspecified Anemia. According to the criteria, admission at the acute inpatient level of care is required for patients with anemia and hemodynamic instability, active hemolysis, active bleeding that could not be controlled in the emergency department or during the period of observation, also in cases of altered mental status that is severe or persistent, recurrent syncope or near syncope episodes, cardiac arrhythmias of immediate concern, acute peripheral ischemia, high-risk low platelet count, acute renal failure, clinically significant symptoms such as heart failure, chest pain, myocardial ischemia, dyspnea. The admission at the acute inpatient level of care is also indicated for patients with anemia who require pulmonary artery catheter or other invasive monitoring, patients who need urgent inpatient surgery, or some other clinical conditions that were not relevant to this clinical case.

The review of the medical records clearly demonstrated that the patient had none of the circumstances listed in the criteria. It was indicated in the chart that the patient had no symptoms of anemia.

Neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care.