Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecological
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. The reviewer has upheld the health plan's determination.

This patient presented to the hospital with past medical history of severe anemia secondary to heavy menstrual bleeding and requiring multiple transfusions in the past. She had been previously managed on oral contraceptive pills. The patient presented with worsening shortness of breath 2 months. Patient reported getting short of breath when walking to the bathroom which did not happen before. She reported associated dizziness and lightheadedness and intermittent swelling of the right lower extremity which had resolved. She had recently restarted taking oral iron supplements. She had a hemoglobin of 4.5 with hematocrit of 17 and a mean corpuscular volume of 58.5 on examination. She had a prothrombin time (PT) of 14.2 with a normal international normalized ratio (INR) and partial thromboplastin time (PTT). Her labs were otherwise normal. A pregnancy urine test was negative.  The patient was consented for blood transfusion and 2 units of packed red blood cells were ordered. She was hemodynamically stable with severe anemia likely secondary chronic losses from uterine fibroids.

Based upon a review of the medical records and the standards of care, there was no medical necessity for admission to acute inpatient level of care. In this case, the patient presented with anemia of chronic disease and stable presentation and vital signs. This was appropriately addressed in the Emergency Department with a 2 unit blood transfusion. There were no episodes of instability or acute events that would require admission to acute inpatient level of care. The patient was noted to lack any need for surgical intervention and did not require acute stabilization. Plan was appropriately made for both obstetrics/gynecology and Hematology consultation as an outpatient. There were no findings to support acute intervention beyond the blood given in the emergency department.
Initial evaluation of the patient with acute abnormal uterine bleeding (AUB) should include a prompt assessment for signs of hypovolemia and potential hemodynamic instability. This was not present in this case as the patient had normal vitals and was stable per the physician documentation. If the patient was hemodynamically unstable or has signs of hypovolemia, intravenous access with a single or two large bore intravenous lines would be initiated rapidly as should the preparation for blood transfusion and clotting factor replacements. Given this was not present, this was not an indicated step in her management. After the initial assessment and stabilization, the next step is to evaluate for the most likely etiology of acute AUB so that the most appropriate and effective treatment strategy to control the bleeding can be chosen. In this case, there was noted to be chronic blood loss due to fibroids and menses. Thus, she was typed and crossed for 2 units of blood and this was administered in the Emergency Department. There was no vaginal or gastrointestinal (GI) bleeding noted or documented. Thus, there were no sources of ongoing losses.
The patient was noted to have anemia of chronic loss and of blood loss in the setting of menorrhagia. There was no acute blood loss and vital signs remained stable. The patient had no passage of blood vaginally during the assessment. Given these findings, the patient could have been safely and effectively managed at a lower level of care and would not have been medically necessary for the acute inpatient level of care given the lack of an acute presentation with instability. Thus, the requested inpatient stay was not medically necessary for this patient as reviewed in concert with recommendations from the American College of Obstetrics and Gynecology.