Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia.
Treatment: Inpatient Admission.
The health plan denied the inpatient admission. 
The health plan's determination is upheld.

The patient is a male who presented for care to the pediatric emergency department (ED) after being referred by his primary care doctor for treatment of anemia. He presented to the pediatrician for concerns of fatigue, puffy eyes, and possible tactile fevers, as well as a significant diaper rash over the past month. At his pediatrician's office, he had initially found to be anemic, and he was started on iron supplementation. He followed up with worsening labs, and he was found to be nonadherent to his iron therapy. At this time, his reticulocyte was increased, and his total iron-binding capacity (TIBC) level was decreased. He was seen in the hematology clinic for normocytic anemia and thrombocytosis in the setting of iron deficiency that showed a low ferritin but normal TIBC. Due to some concerns for possible malabsorption, such as celiac disease, and possible underlying anemia of chronic disease, further evaluation was recommended.
On arrival to the ED, his pulse was 152 beats per minute (bpm), his temperature was 99.2 Fahrenheit, and he had normal oxygen levels. He was noted to be pale appearing on exam. His complete blood count (CBC) was remarkable for a hemoglobin of 4.5, a mean corpuscular volume (MCV) of 68.8, a reticulocyte count of 3.2%, an iron level of 27, a transferrin of 158, an iron saturation of 14%, and TIBC of 198, and an infectious disease work-up to include influenza, respiratory syncytial virus (RSV), and COVID-19 was negative. An ultrasound-guided intravenous (IV) line was placed, and he was admitted for further treatment.
It was noted in the impression that his anemia was of unknown origin, unlikely to be iron deficiency as his TIBC level was normal. The plan was to transfuse 5 milliliters per kilogram (mL/kg) of packed red blood cells (PRBCs), with further transfusions to be based on posttransfusion labs. Additional lab studies to include erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), vitamin B12, folate, and hemoglobin electrophoresis were sent. Urine studies were also sent for urine osmolytes and urinalysis, evaluating for nephrotic syndrome. A stool guaiac was also sent.
After his admission to the inpatient unit, he was stable with no acute events. Following multiple PRBC transfusions, his hemoglobin improved from 4.7 to 8.0, and his ESR and CRP were within normal range. A skeletal survey was performed due to concern for Langerhans cell histiocytosis, but this was read as normal. He was deemed stable and discharged home with close outpatient follow-up.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of inpatient emergency hospital admission was not medically necessary for this patient. 
This patient was admitted with anemia, with a somewhat unclear etiology, possibly at least partially related to iron deficiency. He was admitted to the hospital primarily for red blood cell transfusion, with the expectation that his hemoglobin would improve with treatment. While this transfusion was clinically appropriate given his clinical status, the acute inpatient level of care was not clearly required for this treatment. Typically, admission to the acute inpatient service is appropriate for those with unstable vital signs, but do not improve with an alternate level of care, for those with active and ongoing bleeding or hemolysis, for those with abnormal mental status of unclear etiology, or for those with associated comorbid conditions that require urgent assessment and treatment.
He had no other lab abnormalities or other underlying comorbid conditions that required medical management. In addition, his stay in the hospital was quite short, and he could have been safely managed at an alternate level of care.