Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/ Gastrointestinal/Gastrointestinal Bleeding/ Bleeding of Intestines/ Gastrointestinal Hemorrhage
Treatment: Inpatient Hospital/ Inpatient Emergency Admission
The health plan has denied the inpatient emergency admission. 

The health plan's determination is upheld. 

The patient is a female with a medical history of depression. She presented to the emergency department with melena and bright red blood in her stool, dizziness, lightheadedness, and nausea. The patient's vital signs were unremarkable. The physical examination was notable for a soft, nontender, nondistended abdomen. Laboratory studies showed a low platelet count of 157 kilograms per microliter (K/uL), an unremarkable comprehensive metabolic panel, and a negative stool occult blood test. She was treated with intravenous fluids, pantoprazole, and hydrocortisone, followed by Cortrosyn. She was made nil per os. The day after admission, the patient's laboratory studies showed an unremarkable complete blood count, an unremarkable comprehensive metabolic panel, and low cortisol levels of 1.2 micrograms per deciliter (mcg/dL), 2.1 mcg/dL, and 21.6 mcg/dL. A computed tomography scan of the abdomen and pelvis was reported as normal. The following day, laboratory studies showed a low platelet count of 171 K/uL and an unremarkable comprehensive metabolic panel. A Gastroenterology consultation noted a report of melena with no evidence of any gastrointestinal hemorrhage; they recommended follow-up care with the patient's established primary care physician and for her to report to her primary care if any melena or rectal hemorrhage. The patient was reported to be stable for discharge. She was discharged on famotidine, fludrocortisone, and hydrocortisone, with a plan for Gastroenterology, Endocrinology, and Primary Care follow-up appointments.

The inpatient level of care is not supported as medically necessary, and the care provided could have been provided at an alternate level of care.

In this case, the patient presented with reported melena, bright red blood in her stool, dizziness, lightheadedness, and nausea. However, she was not anemic, did not have any ongoing bleeding, and her hemoglobin remained stable. The patient had close monitoring, which was warranted as bleeding can be severe and sudden in onset. Endoscopic procedures were not deemed necessary. She was appropriately treated with a proton pump inhibitor. Although she had low blood pressure and was found to have low cortisol, she responded quickly to therapy with corticosteroids; she did not have a persistent adrenal crisis. All of the measures that were undertaken, including monitoring, laboratory studies, a Gastroenterology consultation, corticosteroid therapy, and proton pump inhibitor therapy, could have been performed in sequence after presentation and without an acute inpatient level of care, at an alternate level of care [1-6].

Per the Milliman Care Guidelines for Gastrointestinal Bleeding, Upper, none of the criteria to support the inpatient level of care is met.
Per the Milliman Care Guidelines for Systemic or Infectious Condition General Recovery Guidelines (GRG), none of the criteria to support the inpatient level of care is met.
Per the Milliman Care Guidelines for Gastroenterology GRG, none of the criteria to support the inpatient level of care is met.