Appeal type: Medical necessity
Decision: Upheld

Diagnosis: acute blood loss anemia.
Treatment: Inpatient hospital stay.
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

This is a case of a patient admitted to the hospital for diagnosis of acute blood loss anemia. The patient presented with a chief complaint of deep vein thrombosis (DVT) in the left leg, vaginal bleeding, and anemia. The patient was seen by primary care for routine annual physical and started on Eliquis for DVT. She was recommended to have an inferior vena cava filter placement and found to have hemoglobin 6.9. She was admitted for a blood transfusion. A gynecology consult was requested for heavy periods. Vital signs showed blood pressure 147/69, temperature 99.9F, pulse 100, respiratory rate 16 and oxygen(O2) saturation 98%. The patient received blood transfusion and pelvic ultrasound showed a round echogenic structure within the endometrial cavity thought to be polyp versus second endometrium. Conservative medical management was recommended and after transfusion she was deemed to be medically stable for discharge home.

Medical necessity of admission has not been established. According to Milliman Care Guidelines (MCG) Health Anemia, Iron Deficiency or Unspecified guidelines and the documentation submitted the patient did not have hemodynamic instability, hemolysis, bleeding that could not be controlled, altered mental status, syncope, arrhythmia, peripheral ischemia, high risk of low platelet count, acute renal failure, or clinically significant comorbid conditions such as heart failure or chest pain. The patient did not require arterial line or surgical intervention.

Also, according to Up-to-date, 2021:
"Life-threatening causes- Pregnancy less than or equal(<=) to 20 weeks gestation - Life-threatening causes of genital tract bleeding associated with a pregnancy less than 20 weeks gestation include:
1) Ruptured ectopic pregnancy - Clinical manifestations typically appear 6 to 8 weeks after the last normal menstrual period but can occur later. 
2) Retained products of conception (RPOC) - Patients may present with vaginal bleeding, fever, uterine tenderness, or pelvic pain. Necrotic RPOC may become infected, leading to sepsis or toxic shock syndrome. RPOC may also prevent uterine contraction following miscarriage causing uterine atony and persistent, possibly life-threatening, hemorrhage.
3) Complication of pregnancy termination - Though uncommon, complications of pregnancy termination include hemorrhage resulting from cervical or vaginal lacerations, uterine perforation, RPOC, or uterine atony.
Pregnancy greater than( >)20 weeks gestation - Life-threatening causes of genital tract bleeding in pregnancy after 20 weeks gestation and the peripartum period include:
4) Placental abruption - The classic symptoms and signs include dark vaginal bleeding (>80 percent of patients), abdominal pain (>50 percent), uterine contractions, and uterine tenderness. Importantly, the amount of vaginal bleeding does not correlate with the extent of maternal hemorrhage and cannot be used to gauge the severity of abruption.
5) Placenta previa - Most patients present with painless bright red vaginal bleeding, many have uterine contractions as well, but a few are asymptomatic until labor begins.
6) Uterine rupture - This complication is rare but often catastrophic for mother and fetus. It is more likely in women who have had prior cesarean sections (scarred uterus) or following trauma, such as a motor vehicle collision. Patients may develop hemodynamic instability, sudden worsening of abdominal pain, persistent and profound fetal bradycardia, and loss of uterine contour.
7) Postpartum hemorrhage (PPH) - PPH is diagnosed when bleeding results in signs and symptoms of hypovolemia, such as dizziness, tachycardia, syncope, sweating, and hypotension. 
Other genital tract causes - Other life-threatening causes of genital tract bleeding can include:
8) Acute heavy menstrual bleeding - Treatment of this condition may include high dose intravenous estrogen.
9) Genitourinary trauma (including sexual and physical abuse) 
10) Uterine arteriovenous malformation (AVM) - Patients classically present with sudden onset of bleeding that is refractory to hormonal treatment. The diagnosis can be made using pelvic US with Doppler."
The patient in this case had vaginal bleeding but was not found to have a life-threatening cause such as pregnancy, genitourinary trauma, or uterine arteriovenous malformation. The patient did not have hemodynamic instability and responded to the treatments given including transfusion.
Although the patient had needs best addressed in the hospital setting the monitoring, diagnostic workup and therapeutic interventions prescribed could have been safely administered at a lower level of care. Therefore, medical necessity of an inpatient admission has not been established.