Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vaginal Bleeding and Lightheadedness
Treatment: Full Hospital Admission
The insurer denied the full hospital admission.
The health plan's determination is upheld.

This patient is a female who presented to the emergency room (ER) and was noted to have heavy bleeding over the past 29 days. She was noted to have an episode of tachycardia up to 154 beats per minute (bpm) when removing her underwear but her pulse was down to 78 following that episode. She had bled into an entire linen chux at admission. She had abdominal cramping. She was changing a tampon every 5 minutes. She was noted to have a weight of 106 kilograms (kg) with a heart rate of 99 and an oxygenation of 100 percent (%) on room air in triage. She had a respiratory rate of 18 breaths per minute. Her blood pressure was elevated at 158/95, which was consistent with hypertension. She was alert and oriented. A recheck of blood pressure was 134/69 with a heart rate of 90 to 96 on monitoring. The repeat vital signs at 9 AM were 156/97 with a heart rate of 82. She had 100% oxygenation on room air. The patient had a good urine output in the ER. She had an 18 gauge intravenous (IV) needle placed. She remained stable and was given a blood transfusion and her blood pressure and heart rate remained normal at 128/68 and 76 respectively. Her vital signs remained stable throughout triage and the ER encounter.

The patient's laboratory studies noted anemia with a hemoglobin of 7.9 grams per deciliter (g/dL) with a hematocrit of 27.4% with elevated platelets. The mean corpuscular volume (MCV) was 75, consistent with chronic and longstanding iron deficiency anemia. The serum creatinine was normal at 0.69. Her liver function tests (LFT) were normal.

The patient was admitted to the gynecological (GYN) service. The patient was noted to have progressively heavy periods over the past two years. The patient reported that her bleeding had increased over the past few periods. She had cramps with menses and used over the counter Tylenol or Ibuprofen for control of her pain. She presented to the ER after working in the prison as a correctional officer and feeling lightheaded. She had no syncope or loss of consciousness. She reported no bleeding tendency. She had a prior history of tonsillectomy and laparoscopic cholecystectomy. She also had exercise induced asthma.

The patient was to receive three units of blood. She had tolerated the first well in the ER. The ultrasound noted a 10-millimeter (mm) endometrial stripe and intramural or subserosal myoma of 8-centimeter (cm) dimension. The plan was made for IV Tranexamic Acid with oral Tranexamic Acid with high dose Progesterone. 

The 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 continued to have normal heart rate and normal to elevated blood pressure. If the patient was hemodynamically unstable or had signs of hypovolemia, IV access with a single or two large bore IV 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, the patient was given a blood transfusion and underwent ultrasound for diagnosis of leiomyoma. She responded with an appropriate rise in hemoglobin. This was achieved starting in the ER. There was also oral Iron given. These are appropriate interventions for chronic, longstanding anemia which were noted in this case based upon the complete blood count and MCV.