Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Uterine Fibroids.
Treatment: Inpatient admission.

The insurer is denied coverage for inpatient admission.  The denial is overturned. 

This female patient has a history of hypertension, fibroids and iron deficiency anemia (not on iron pills) who presented to the emergency department (ED) with complaints of vaginal bleeding times 3 weeks.  She reported that she used 3 to 6 maxi pads during the day with large clots, and felt lightheadedness, palpitations, and generalized weakness. She also had muscle aches with walking.  Her vital signs were the following: blood pressure 150/100, pulse 103, temperature 98.6 F, respiratory rate 18 and oxygen saturation of 100%. The assessment was vital signs significant for borderline tachycardia, likely secondary to known fibroids.  Her hemoglobin was 4.4 and hematocrit was 14.7. The patient received 3 units of packed red blood cells. The patient felt more dizziness in the ED. A trans vaginal ultrasound showed multiple large fibroids, with the largest measuring 10 centimeters. Gynecology was consulted, and the patient had large amounts of vaginal bleeding during the evaluation and became less stable. She was given Tranexamic acid and Provera emergently. The patient was admitted on to the Gynecology service. An endometrial biopsy was performed with results pending.  Her bleeding resolved with treatment, and her tachycardia also resolved. Her hematocrit improved to 24.3. The treatment plan was to continue Provera and taper the dose. Her  options were also discussed for long term management which included a hysterectomy, uterine artery embolization, or expectant management. Arrangements for outpatient follow up were made to discuss the endometrial biopsy results. 

This patient had tachycardia. In other words, she was symptomatic for anemia. This patient also fulfills the transfusion guidelines for use of blood components: her hemoglobin was less than 8g/dl and she was symptomatic, so transfusion was necessary. She was transfused and admitted and underwent a D&C (dilation and curettage procedure) and was treated with tranexamic acid to stop the bleeding. Transfusions can done routinely in outpatient settings (oncology clinics, infusion centers, even at home). So the need for transfusion is not a reason for admission. However, because of continuous bleeding, admission was medically necessary to manage the bleeding.  Management included a D&C, tranexamic acid and a progestin.  Once the bleeding had been controlled and the patient was stable, she was discharged home to be followed as an outpatient.
MCG lists the clinical indication for inpatient care for patients with anemia. These include: active massive hemorrhage, active hemolysis, cognitive impairment, tachycardia, orthostatic changes, heart failure, chest pain, syncope. This patient was actively bleeding and was tachycardic, admission to stabilize the patient and stop the bleeding was medically necessary.

The health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is overturned.  The medical necessity is substantiated.