Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Upper gastrointestinal bleed.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult male who had presented to the emergency department (ED) by transfer from an outside hospital for an upper gastrointestinal (GI) bleed. The patient had significant medical history of alcoholism, prior Mallory-Weiss tear, and esophageal varices. The patient had stated he awoke that morning, nauseous and vomited bright red blood. He admitted to drinking a pint of vodka daily. His last drink was the previous evening before bed and he started to feel tremulous with a headache. He received Rocephin, octreotide, and magnesium prior to arrival. The patient's vital signs showed a respiratory rate of 22 breaths per minutes. Labs revealed glucose 61, total carbon dioxide (Co2) 17, high anion gap 25, elevated liver function tests, aspartate aminotransferase (AST) 66, bilirubin 2.04, white blood cell (WBC) count 12, and hemoglobin (Hgb) 13. The patient was COVID-19 positive. Electrocardiogram (EKG) showed prolonged QT with QTC 482. The patient had anion gap metabolic acidosis, hematemesis, esophageal varices, and alcohol withdrawal. Admitting orders included octreotide drip, Rocephin one-gram intravenous daily, intravenous fluids, intravenous Protonix every 12 hours, Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol, Ativan protocol, folic acid, thiamine, 100 milligrams intravenous phenobarbital then oral every eight hours, Gastrointestinal consult, nothing by mouth, and placement in isolation.
On day #2, on physical exam, the patient was tremulous. He endorsed a severe headache. Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score was with moderate withdrawal to 17. The patient received phenobarbital and a total of nine milligrams Ativan, both intravenous and oral in the first 24 hours. The patient had an episode of blood pressure at 97/55. White blood cell (WBC) count trended up to 14. The Gastrointestinal physician indicated to continue with intravenous octreotide, intravenous Rocephin, intravenous Protonix and esophagogastroduodenoscopy that afternoon. Esophagogastroduodenoscopy was without evidence of variceal bleeding; there was a suspected Mallory-Weiss tear which seemed to have resolved.
On day #3, Clinical Institute Withdrawal Assessment for Alcohol (CIWA) was up to 13 and the patient was very anxious. He received Ativan two milligrams. The patient's hemoglobin was stable at 12, with no further hematemesis. The patient pressed the CODE BLUE button in his room, demanding to leave the hospital. He was also found by nursing staff wandering the halls, despite him being on isolation for COVID-19. The patient told the attending physician he was going to leave and called his father for a ride. Despite further discussion with the attending and nursing staff, the patient was not agreeable to staying in the hospital for further monitoring and signed out against medical advice. The patient was instructed that his ciprofloxacin and pantoprazole was sent to his pharmacy of choice prior to his discharge.

The proposed inpatient hospital admission was not medically necessary.

While the care as provided was medically appropriate, the level at which the care was rendered was not medically necessary at the acute level. Despite the patient's presentation, the care as provided could have been rendered at a lower level of care. The patient had gastrointestinal bleeding and alcohol use; yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for prolonged nothing by mouth status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. The endoscopy showed no bleeding source. As such, the care could have been rendered at a lesser level.