Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecological 
Treatment: Inpatient Hospital 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is an obese female with past medical history of dysfunctional uterine bleeding, who was brought to the emergency department by ambulance complaining of syncopal episode. The patient described that she began having a headache all day and dizziness. When she stood up to walk to the bathroom, she began to feel dizzy again and fell to the floor. She did not hit her head. The patient was noted to have dysfunctional uterine bleeding and having bleeding for 3 weeks, including 5 pads per day with passage of clots. She was otherwise in a normal state of health. The patient denied fever, chills, chest pain, shortness of breath, nausea, vomiting, diarrhea and denied sick or COVID (Coronavirus) contacts. The patient had no pertinent past medical or surgical history. There was no pertinent family history. The patient is a nonsmoker and does not use alcohol. Her review of systems was negative with the exception of a positive review of systems for dizziness, syncope, lightheadedness, and headaches. The subject under review is the medical necessity of the inpatient stay.

The health plan's determination is upheld.

The patient was noted to have chronic and longstanding iron deficiency anemia in the setting of menorrhagia that was not noted to be acute as vitals were stable. She received two units of blood which can be provided at lower level of care status. There was no hypotension and there was no tachycardia noted. The Milliman Care Guideline (MCG) entitled "Obstetric and Gynecologic Disease General Recovery Guidelines (GRG)" was reviewed in concert with the medical records in this case. This guideline lists the specific criteria to be considered when an inpatient admission is medically necessary. The specific criteria in this case are titled "uterine bleeding with high-risk features indicated by one or more of the following: Active major hemorrhage, coagulopathy with active bleeding, gestational trophoblastic disease, pregnancy related bleeding, or severe anemia." In this case, the patient did not have an active major hemorrhage and the bleeding is noted to be stable and not acute resulting in abnormal vital signs or cardiovascular collapse. The patient had normal pulse rate and was maintained with intravenous fluids (IVF) and packed red blood cells due to her chronic anemia with the menorrhagia. There was no coagulopathy as her labs were normal. She also had no severe anemia (less than [<] 6 grams per deciliter [g/dL]). The patient had a hemoglobin of 7.7 g/dL, which would not meet these criteria. Severe anemia in the MCG is defined as that which is accompanied by altered mental state, chest pain, exertional dyspnea, or syncope. There can also be inadequate perfusion. This can also be seen with transfusion or volume replacement where there is in effective resolution of tachycardia or orthostatic vital sign changes. In this case, the patient had no tachycardia or orthostatic vitals. She had normal oxygenation on room air at 100% (percent). She had no chest pain or dyspnea. Thus, she did not meet the criteria for severe anemia. Based upon the presentation with need for 2 units packed red blood cells (PRBCs) and intravenous (IV) fluids, the patient could have had all procedures at a lower level of care status. There was no medical necessity for admission to inpatient level of care.