Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission. 
The health plan's determination is upheld.

The patient is a male with medical history of hypertension, hyperlipidemia, coronary artery disease status post percutaneous coronary intervention, chronic obstructive pulmonary disease, carotid artery stent, obstructive sleep apnea, anxiety, and prior tobacco abuse and heavy alcohol abuse.

He presented to the emergency department with melena for a couple of days, fever, rash, and persistent mid-epigastric pain. He had been seen the prior day, and reportedly had endoscopy with finding of esophageal and gastric ulceration and possible transesophageal echocardiogram with finding of cardiac vegetations but left against medical advice. Vital signs were notable for elevated temperature of 99.8  Fahrenheit (F), tachycardia with heart rate of 118/minute, and tachypnea with respiratory rate of 22/minute. Physical examination was notable for soft abdomen with mild diffuse tenderness. Labs showed low hemoglobin of 8.0 grams per deciliter (g/dL) and hematocrit of 26.5%, unremarkable comprehensive metabolic panel, and Hemoccult-positive stool. Urinalysis was positive for bacteria. Chest x-ray showed right basilar discoid atelectasis and prominent loops of gas looks extremely good bowel in the upper abdomen. Computed tomography scan of the abdomen and pelvis showed mild distention of the right colon which may be incidental due to the presence of stool, nonspecific bilateral inguinal lymphadenopathy which appears increased since prior exam, and possible urinary bladder wall thickening. He was treated with intravenous fluids, pantoprazole, and oral sucralfate. He was made nothing by mouth (NPO).

The next day, labs showed low hemoglobin of 7.6 g/dL and hematocrit of 24.4%, and unremarkable comprehensive metabolic panel. Gastroenterology consultation concluded that he had proton pump inhibitor twice daily, clear liquid diet, hold Plavix, if possible, plan for esophagogastroduodenoscopy and colonoscopy on Monday, blood cultures, and consider Cardiology consultation for transesophageal echocardiogram for vegetations. He was found to have eloped from the hospital. The subject under review is the medical necessity for the inpatient hospital stay.

The health plan's determination is upheld.

The patient presented with visible gastrointestinal bleeding characterized by melena, and reportedly had recent esophagogastroduodenoscopy for evaluation with finding of gastric ulcers; monitoring was warranted as bleeding can be severe and sudden in onset [1-6]. Additionally, the patient had cardiovascular disease, which can increase the risk of adverse outcomes with bleeding [2,3]. However, there was no hypotension, hemodynamic instability, sharp drop in hemoglobin, or visible ongoing gastrointestinal bleeding. Appropriate therapy was performed with proton pump inhibitor, and endoscopic evaluation was offered but not elected by the patient. All of the measures that were undertaken, including monitoring, proton pump inhibitor therapy, and Gastroenterology consultation, could have been performed without acute inpatient level of care, at a lower level of care status [1-6].