Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient was sent to the hospital from a nursing home secondary to a low hemoglobin for a blood transfusion. The patient was recently discharged from the hospital after a blood transfusion of 1 unit of packed red blood cells, improving the hemoglobin from 6 grams per deciliter (g/dL) to 7.9 g/dL. The patient has a history of prostate cancer with metastases and anemia of chronic disease at baseline. The patient was receiving chemotherapy with androgen deprivation therapy (ADT) and cabazitaxel and received granulocyte colony-stimulating factor since his last chemotherapy infusion. On arrival, the vital signs were stable, with a normal temperature, heart rate, and oxygen saturation. The blood pressure was 98/58. On exam, the patient was lying in bed with no acute distress. The cardiopulmonary exam was unremarkable. Neurologically, he was intact. The hemoglobin was 7, and the white blood cell count was elevated to 29,000. Electrolytes and renal function were normal. Alkaline phosphatase was elevated at 590. Aspartate aminotransferase (AST) was 67 with an alanine aminotransferase (ALT) of 12. A chest x-ray showed atelectasis, no infiltrates, diffuse sclerotic osseous disease compatible with metastatic prostate cancer.

The medical team ordered a transfusion of 1 unit of packed red blood cells, iron studies, and follow-up hemoglobin and hematocrit for the following morning. They also checked the lactate dehydrogenase (LDH) haptoglobin and fecal occult blood test. They documented, if positive fecal occult blood test, consideration for gastrointestinal (GI) consultation. The medical team also started the patient on empiric antibiotics due to the leukocytosis. An infectious disease (ID) consultation was requested, who saw the patient and noted the leukocytosis was secondary to the colony-stimulating factor injection given with chemotherapy and unlikely to be an infectious process. All of the cultures were negative. They stopped all the antibiotics and signed off.

The following day post-transfusion, the patient's hemoglobin was 8 g/dL. The patient remained in the hospital, with plans to return to the nursing home when medically stable. Vital signs were stable. The patient had no new complaints. A repeat hemoglobin was 7.9 with platelets of 91,000. The LDH was slightly elevated. The electrolytes and renal function remained stable throughout the hospital stay. The computed tomography (CT) scan reconfirmed the knowledge of widespread metastases. The patient was deemed medically stable for discharge.

At issue is whether the inpatient stay was medically necessary for this patient.

The requested health service/treatment of inpatient stay was not medically necessary for this patient. This patient was sent to the hospital to receive a blood transfusion. He has a history of prostate cancer with metastatic disease. He was undergoing chemotherapy and treatment with granulocyte colony-stimulating factors, experiencing leukocytosis. There was no evidence of an infection anywhere to require antibiotics. The patient only needed a blood transfusion, repeat hemoglobin and discharge to the skilled nursing facility.  Care could have been provided at a lower level for a blood transfusion and post-transfusion hemoglobin only. There was no evidence of an infection on the imaging; there was no evidence of sepsis. The infectious disease specialist, who evaluated the patient, confirmed that the leukocytosis was caused by the granulocyte colony-stimulating factor and not by an infectious source.

The post-transfusion hemoglobin was stable. The inpatient level of care was medically unnecessary for this patient. Inpatient hospitalization is not supported by medical care guidelines.