Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Admission. 
The denial is overturned. 

The patient is a female with a past medical history significant for anemia and colonic polyps who was referred to the emergency department due to rectal bleeding that had been going on for three days, since the patient had a colonoscopy and polyp removal. It was reported that the patient had extensive polyps throughout her colon, which were removed. When seen by the admitting physician the patient denied dizziness, weakness, shortness of breath, or chest pain. On the physical exam, she was afebrile. The heart rate was 87 beats per minute, blood pressure was 130/78, respiratory rate was 18 breaths/minute (min), and oxygen saturation was 99% on room air. She was awake, in no acute distress, sitting upright, and she was able to follow commands. The patient was awake, alert, and oriented times three. Her lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular rate and rhythm, without murmurs, rubs, or gallops. The abdomen was soft, nontender to palpation, with normal bowel sounds, and without guarding or rebound. The rest of the physical exam was unremarkable.
Laboratory evaluation revealed that her white blood cell count was 7.2, hemoglobin was 13.6, hematocrit was 41.1, and platelets were 254. The patient was admitted to the hospital with a diagnosis of lower gastrointestinal bleeding that was attributed to the recent removal of colon polyps. The admitting physician noted that the patient had dark red blood on the rectal exam. She was admitted to the hospital for a colonoscopy. It was noted that the patient had ulcers with visible vessels. Therefore, endoclips were placed. The patient was kept nothing by mouth (NPO) post-procedure since she still had mild bleeding. Subsequently, her diet was gradually reintroduced and advanced.
At issue is the medical necessity of Inpatient Admission.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Inpatient Admission was medically necessary for this patient.
The admission was reasonable due to ongoing active bleeding following the procedure. The repeat colonoscopy revealed high-risk features including ulcers with visible vessels, which required endoclips placement. The patient continued to have rectal bleeding and developed acute blood loss anemia. The patient had ongoing bleeding despite a recent colonoscopy with recurrent episodes of hematochezia even after the patient had a colonoscopy. Her rectal bleeding manifested in acute blood loss anemia, which was documented (hemoglobin went down from 13.6 to 11.8). Furthermore, the endoscopic studies revealed ulcers with visible vessels, which had a high potential for re-bleeding. The severity of the patient's condition, including the risk of bleeding in the setting of acute blood loss anemia, justified admission at the acute inpatient level of care. The admission at the acute inpatient level of care was completely reasonable, given the clinical circumstances.
Therefore, the requested health service/treatment of Inpatient Admission was medically necessary.