Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anemia; Chronic Kidney Disease; Heart Failure

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned.  

This male patient has a history of diabetes and chronic kidney disease (CKD) and presented to the Emergency Room (ER) with weakness, fatigue, and dyspnea. The patient denied bleeding. The patient was noted to be pale, with a pulse of 82 and oxygen saturation (O2 sat) of 100%. The patient's labs showed severe anemia with hemoglobin of 5.8 g/dL and a creatinine (Cr) of 3.36. The patient's chest x-ray (CXR) showed evidence of heart failure. The patient was admitted to the hospital for blood transfusion and hydration. Nephrology and hematology were involved in this patient's care. Following transfusion, the patient's hemoglobin improved slightly. The patient was given iron and Aranesp. Several days later, the patient's condition stabilized and he was discharged. 

Per Carson et al. (2016), "It is good practice to consider the hemoglobin level, the overall clinical context, patient preferences, and alternative therapies when making transfusion decisions regarding an individual patient." The authors state a restrictive red blood cell (RBC) transfusion threshold, in which the transfusion is not indicated until the hemoglobin level is 7 g/dL, is recommended for hospitalized adult patients who are hemodynamically stable, including critically ill patients, rather than when the hemoglobin level is 10 g/dL. 

Per Shaikh and Aeddula (2020), "Anemia in chronic renal disease is a multifactorial condition, the widely accepted etiology being decreased renal production of erythropoietin, the hormone that is responsible for the stimulation of red blood cells production. Decreased erythropoietin has recently linked with downregulation of hypoxia-inducible factor (HIF), a transcription factor that regulates gene expression of erythropoietin. Other mechanisms include uremia (leading to RBC deformity responsible for hemolysis), folate and vitamin B12 deficiency, iron deficiency, bleeding due to dysfunctional platelets, and rarely blood loss from hemodialysis. Red blood cell (RBC) fragmentation by injured renovascular endothelium in selected conditions such as glomerulopathy and malignant hypertension exacerbates the anemia, which explains why anemia can be particularly severe in renal glomerulopathies, including glomerulonephritis, diabetic nephropathy, for the degree of excretory failure."

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient. This patient presented with critically low anemia with evidence of high output cardiac failure and acute kidney injury (AKI). Acute hospitalization was justified for correction of his anemia, correction of his volume status, and management of kidney function and electrolytes. 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The medical necessity is substantiated. The carrier's denial of coverage for the inpatient hospital admission should be overturned.