Appeal type: Medical necessity
Decision: Upheld

Diagnosis. Gynecological. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission. 
The health plan's determination is upheld.

The patient was a gravida (G)3 para (P)3 female with vaginal bleeding after the removal of an intrauterine device (IUD) that was in the endocervical canal a few days prior. Her temperature was 97.9 Fahrenheit (F) with a heart rate 92 and blood pressure of 104/70. The patient had oxygenation of 100% on room air. She reports suprapubic pain that was 8 out of 10. The patient was noted to have no other prior medical history.  The patient had an IUD replaced 2 months ago and started bleeding from it. The IUD was removed on the prior Friday, and she was still bleeding and using 4 pads per day. The patient was also complaining of dizziness and weakness.

The patient was admitted for evaluation of symptomatic anemia likely resulting from 2 months of persistent vaginal bleeding. Obstetrics/gynecology (OB/GYN) recommended the patient get 1 unit of packed red blood cells and that the symptoms resolved she could be discharged to home with the oral contraceptive pill taper. She was to follow-up in 1-2 weeks. The taper instructions were given, and the patient and husband were agreeable with Plan at that time. The patient was noted to have normal coagulation studies and a normal complete metabolic panel and lipase. The patient had a negative antibody screen.

The health plan's determination is upheld in whole.

In this case, based upon a review of the medical records and the national Milliman Care Guidelines (MCG) Care Guidelines, there would be no medical necessity for acute inpatient stay in this case. The patient was noted to have chronic and longstanding iron deficiency anemia in the setting of menorrhagia that was not noted to be acute or active in a patient with stable vital signs. There was prior placement of an IUD, and this had been recently removed. There was no acute blood loss and vital signs remained stable. This was documented by emergency room (ER) staff and obstetrics/gynecology (Ob/Gyn) staff. There was no hypotension and there was no tachycardia noted.
The MCG Guideline entitled "Obstetric and Gynecologic Disease General Recovery Guidelines (GRG)" was reviewed. This guideline lists the specific criteria to be considered when an inpatient admission is medically necessary.  She did not meet the criteria for severe anemia. Rather, the patient had chronic anemia that was worsened by menorrhagia. This is evidenced by her hemoglobin of 7.6 and mean corpuscular volume (MCV) of 77.6 which supports very long standing iron deficiency anemia. Thus, the patent would be expected to be managed at an alternative level of care than inpatient in this case. This care could have been performed at a lower level of care status. Inpatient care would not be medically necessary for the treatment of the patient's condition as presented in this case.

Based upon a review of the American College of Obstetricians and Gynecologists (ACOG) recommendations and MCG Care Guidelines for management of menorrhagia in chronic iron deficiency anemia as seen in this case, this care could be performed at a lower level of care status and would not require admission to inpatient care.