Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastric Ulcers
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

This is an adult with a history of hypertension and benign prostatic hypertrophy who presented to the emergency room complaining of 2 episodes of black stool and 2 episodes of syncope.  The triage notes noted that the patient's blood pressure was 150/98 with a mean blood pressure of 115 mmHg (millimeters of mercury).  Heart rate was 78 with respirations 18 and pulse oximetry 99% (percent) on room air.  The patient had chest pain for 2 days graded 6/10 in severity.  During assessment, the patient was alert and oriented to time, place, person, and situation.  The Glasgow Coma Score was 15.  The patient stated that the reason for visiting the emergency room was fainting.  The patient reported having a syncopal episode the day prior and felt weak with increased chest pain and shortness of breath with exertion for 2 days.  Episodes of dark stool the day prior were reported with skin color pale and diaphoretic upon arrival.  The patient was given 0.4 mg (milligrams) sublingual nitroglycerin and 325 mg aspirin by emergency medical services (EMS).  Computed tomography (CT) of the abdomen and pelvis with intravenous contrast was obtained due to the patient's reports of abdominal pain.  The impression was of no acute intra-abdominal or pelvic inflammatory process with mild constipation.  Chest x-rays showed no evidence of active pulmonary disease.  CT of the head showed no intracranial process.  The patient had positive fecal occult blood and was recommended treatment with intravenous fluids, intravenous proton pump inhibitor, Zofran, along with EKG (electrocardiogram).  Laboratory testing noted that hemoglobin levels were 10.6.  The patient was admitted for further work-up because of gastrointestinal bleeding and syncope.  

An appeal was submitted stating that the patient had a hemoglobin from a year prior of 13.6-15 with his current hemoglobin 10.6.  Esophagogastroduodenoscopy (EGD) revealed 2 nonbleeding cratered gastric ulcers with no stigmata of bleeding in the antrum of the stomach.  The largest lesion measured 8 mm (millimeters) in dimension and the patient had diffuse mildly erythematous mucosa without active bleeding and with no stigmata of bleeding found in the duodenal bulb.  Recommendation at that time included clear liquids, proton pump inhibitor twice a day, trending hemoglobin and hematocrit, no non-steroidal anti-inflammatory drugs (NSAIDs) with a repeat EGD in 12 weeks.  The diet was advanced to soft low fiber, and the patient was noted to be voiding.  The report indicated the patient met clinical criteria for admission due to active bleeding suspected, symptomatic anemia as indicated by 1 or more of the following to include dyspnea and other findings suggesting inadequate perfusion (for example, syncope).  

The Milliman Care Guidelines state that inpatient care regarding gastrointestinal bleeding is indicated when the patient has ongoing active bleeding but is for example, decreasing hematocrit, and when the patient has anemia with presence of clinical findings such as chest pain and dyspnea, both which were noted within the presenting complaints.  Based upon the provided information, it was determined that the inpatient stay was reasonable.  The patient had abnormal hemoglobin and hematocrit levels along with positive occult blood, reports of syncope and chest pain.  Given that the patient required additional work-up and was found to have multiple issues at the time of his presentation, it was determined that inpatient care was appropriate and within standards of treatment.

Based on the above, the insurer's denial must be overturned.  The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for the inpatient admission services is substantiated.