Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe symptomatic anemia 

Treatment: Inpatient admission 

The insurer denied coverage for inpatient admission. The denial upheld.

This patient is a male who has a medical history which includes diabetes as well as coronary artery disease and a prior renal transplant.  The patient presented to the hospital after being sent by his primary care physician for blood transfusion.  Per the physician's note the patient had hemoglobin of 6.8 with decreased appetite as well as weight loss and severe weakness.  The patient also stated he had the inability to walk.  The documentation detailed the patient was also sent to undergo an endoscopy and colonoscopy.  The patient has been complaining of a decreased appetite the last three months and has lost 20 kg.  He complained of weakness throughout and denied melena/hematochezia.  The physician detailed upon further testing it was noted the patient's hemoglobin was 6.1.  The exam revealed the patient was in no apparent distress.  The patient did continue with treatment as an inpatient.  It was recommended he undergo a colonoscopy, however, the following day the patient stated he was not prepared to undergo colonoscopy and indicated he wished to leave the facility.  The patient was discharged.

As per MCG Health guidelines, one of the clinical indications for inpatient admission for anemia is acute renal failure, and this is either a 3-fold rise in creatinine from baseline or a serum creatinine greater than 4mg/dL. This patient's creatinine level was at the highest 3.2mg/dL, which was not a 3-fold increase from baseline of 2.45mg/dL. And patient's creatinine level improved to 3mg/dL after RBC transfusion. Patient's post-transfusion lab showed that patient did not have active hemolysis/bleeding, and patient's clinical picture was not complicated by altered mental status, hemodynamic instability, severe hypertension, cardiac arrhythmias (i.e. EKG was sinus rhythm), or significant electrolyte abnormalities. 

This patient was referred to the hospital for blood transfusion. The patient was noted to have severe symptomatic anemia with Hgb 6.8 as an outpatient. He arrived to the Emergency department (ED) Hgb level was 6.1, which was a significant drop from his baseline Hgb of 8, and his creatinine level was elevated to 3.2 from 2.45 five weeks ago. Given patient's history of coronary artery disease status post coronary artery bypass graft (CABG), and kidney transplant several years ago he was admitted for blood transfusion and anemia workup. However, based on a specified MD note, the patient consented and received 2 units of RBC blood transfusion but did not consent to receiving colonoscopy, inpatient. The patient stated that the colonoscopy could be done as outpatient and left the hospital against medical advice. The patient tolerated the 2 units of packed red cell transfusion without any signs/symptoms, overload reactions or shortness of breath.

The patient's anemia lab values responded appropriately to blood transfusion, and patient did not want further anemia workup (i.e. colonoscopy) as inpatient. Based on this patient's clinical presentation, patient does not meet the MCG Health guidelines recommendation for inpatient admission. However, because patient experienced post-transfusion dyspnea and required oxygen supplementation, patient meets the clinical criteria for observation care. 

Based on nursing notes, patient's respiratory status improved after 11 hours, where patient was breathing with ease on 3 liters nasal cannula (titrated from non-rebreather mask). 

The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.