Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld in whole. 

The patient is a male with medical history of cirrhosis complicated by portal hypertension and esophageal varices, hypertension, hyperlipidemia. He presented to the emergency department with dyspnea and exertional chest pain, as well as black bowel movements for over a week. Esophagogastroduodenoscopy had shown large esophageal and gastric varices, gastritis, and portal hypertensive gastropathy; colonoscopy had shown multiple colon polyps and large, ulcerated nonbleeding hemorrhoids. He reported dyspnea and chest pain upon walking 10 steps or climbing stairs for the prior 2 to 3 days. 

He was treated with intravenous octreotide, pantoprazole, and ceftriaxone. He was treated with transfusion of one unit of packed red blood cells. Gastroenterology consultation concluded that he had anemia and melena; the recommendation was to obtain troponin to rule out cardiac causes for chest pain and dyspnea, cardiology evaluation, computed tomography scan, ultrasound of the legs to rule out deep venous thrombosis, nothing by mouth (NPO) status after midnight for potential esophagogastroduodenoscopy the next day, pantoprazole 40 mg intravenously twice daily, octreotide drip, ceftriaxone 1 g daily, monitor serial blood count every 6 hours, transfuse as needed, and maintain 2 large-bore IVs. 

Computed tomography scan of the abdomen and pelvis showed cirrhosis, evidence of portal hypertension, paraesophageal varices, gastric varices, no active gastrointestinal bleeding, and wall thickening of the ascending colon and cecum which may represent portal hypertensive colonoscopy. Esophagogastroduodenoscopy showed three large columns of large esophageal varices, large gastric varix, gastric antral vascular ectasia, portal hypertensive gastropathy, gastritis, and a Hill grade 2 hiatal hernia; the recommendation was to resume clear diet and advance as tolerated, resume oral pantoprazole daily, increase carvedilol, monitor serial blood count, and consider transfer for further management and transplant evaluation. 

On the day of discharge the patient had no distress. Labs showed low white blood cell count of 2.8 K/uL, low hemoglobin of 8.1 g/dL and hematocrit of 28.3%, and low platelet count of 47 K/uL. He was discharged on pantoprazole and lactulose, with a plan for Primary Care and Gastroenterology follow-up. 

The health plan's determination is upheld. 

In this case, the patient presented with anemia and reported upper gastrointestinal bleeding. However, there was no sustained tachycardia or hypotension, or signs of active gastrointestinal bleeding. The patient had close monitoring, which was warranted as bleeding can be severe and sudden in onset [1-4]. Gastroenterology found portal hypertensive gastropathy and gastritis, but no active bleeding or concern for variceal bleeding. Cirrhosis was not complicated by hepatic encephalopathy, severe ascites, or other complications warranting the inpatient level of care [5,6]. Myocardial infarction was ruled out, and there was no evidence of decompensated heart failure [7,8]. All of the measures that were undertaken, including monitoring, proton pump inhibitor therapy, Gastroenterology consultation, and endoscopy could have been performed without acute inpatient level of care [2-4]. 
The inpatient level of care is not supported by the Milliman Care Guidelines for Chest Pain. 
The patient could have been managed at a lower level of care status.