Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Symptomatic anemia.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission. 

The denial is overturned. 

This is a female patient with a past medical history of gastroesophageal reflux disease (GERD), hiatal hernia, asthma, and anxiety, who presented to the Emergency Department (ED) with complaints of chest pain and sharp left-sided abdominal pain, associated with shortness of breath, which was worse when she would sit or lay down. She also had bilateral lower extremity edema. The patient's electrocardiogram (EKG) noted sinus tachycardia. The patient's lab work was significant for hemoglobin of 6.5. The patient's chest X-ray showed clear lungs with no pleural effusion or pneumothorax. The patient's computed tomography (CT) scan of the chest, abdomen and pelvis was done, and the impression was: no central pulmonary emboli; a small hiatal hernia; and mild skin thickening and subcutaneous soft tissue infiltration of the inferior anterior abdominal wall/pannus which may be chronic or represent cellulitis. The patient was admitted for symptomatic anemia. The patient received two units of packed red blood cells. Post-transfusion, the patient's hemoglobin level was 9.1. Iron studies were completed, and her ferritin was less than 2.0 and iron was 14. The treatment plan also included pantoprazole, Maalox and ferrous sulfate. The patient's condition improved and she was deemed clinically stable for discharge. The patient received discharge instructions to follow-up on her anemia and any abdominal imaging findings at the appropriate interval. 

As per Patel et al. (2020), "Anemia is defined by hemoglobin levels under 13 g/dL [grams per deciliter] in men, and under 12 g/dL in women. Anemia affects roughly 25% of the world population, of which half is caused by iron deficiency, with 2% of American men and 5% of American women affected. Low iron store causes decreased levels of hemoglobin production by the bone marrow. Iron is required for erythrocytes to produce heme for hemoglobin and for vital proteins in oxygen transportation. Metabolically active cells, including myocytes, are highly dependent on this. Previous literature has shown that in patients with untreated iron-deficiency anemia if severe enough, mortality is possible due to either poor tissue oxygenation, or cardiac arrhythmias from left ventricular hypertrophy. There is also high morbidity due to decreased exercise tolerance, increased fatigue, and worsened quality of life index." 

As per Le (2016), "Due to the reduced oxygen-carrying capacity, anemia has serious health implications that affect both morbidity and mortality. Symptoms of anemia range from fatigue and weakness to reduced cognitive performance. Anemic older adults have increased hospitalization and mortality rates. In congestive-heart failure patients, anemia is a common condition (17%) and results in significantly worse functioning capacity and survival rates."

As per Milliman Care Guidelines (MCG), inpatient admission is medically indicated for anemia associated with hemodynamic instability and clinically significant symptoms, such as dyspnea. This was the case for this patient. This patient presented to the Emergency Room (ER) with anemia that was symptomatic associated with shortness of breath and tachycardia. This patient's EKG showed sinus tachycardia with a heart rate (HR) of 119-133, and had low hemoglobin of 6.5 that required 2 units of packed red blood cell transfusion. 

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 should be overturned. The medical necessity is substantiated.