Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute blood loss anemia
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned

The patient presented to the emergency room (ER) with complaints of lightheadedness and syncope. Vital signs in the ER included blood pressure of 102/70 and heart rate 125. Rectal exam revealed black/dark maroon stools. The patient's hemoglobin (hgb) level was 7.5, which had dropped from 11.8 one week prior to arrival. Repeat hgb was 6.5. The patient had acute blood loss anemia. She was started on Protonix and admitted for care. She was given 40 milligrams (mg) of Protonix twice a day and initially kept on nothing by mouth (NPO). Labs were trended and she was started on intravenous (IV) fluids. Based on the findings on exam, her syncope was secondary to a gastrointestinal (GI) bleed. Two units of packed red blood cells (PRBC) were given. The patient had an endoscopy and colonoscopy. The latter showed polyps. The patient was discharged after a period of hemodynamic stability.  

Anemia is common in younger women and is usually due to iron deficiency. If anemia has a slower, subacute onset, younger patients without medical problems can tolerate low hgb levels. Often times, however, in addition to subacute or chronic iron deficiency anemia, young women can have anemia of acute blood loss. In this situation there is less time for the body to become habituated to the low red cell levels and moderately low hgb may coexist with acute symptoms of anemia. Blood transfusions may be required in such situations. This means that a careful and complete clinical assessment is required before blood transfusion is offered and that transfusions should not be given based on low hgb levels alone. Blood transfusions come with some risks and several studies have shown that patients who receive transfusions, on average, stay in the hospital longer, have higher hospital bills, and are generally more ill than patients who did not receive a transfusion. This requires an acute level admission and a two-day total admission on this level is reasonable in these circumstances.

"While standard hgb values some by gender and race and normal value for hgb and hematocrit vary slightly by the laboratory, anemia is usually defined as a hgb level less than 13 grams/ deciliter (g/dL) in males and less than 12 g/dL in females. Currently, guidelines for transfusion of red blood cells (RBC), generally follow a restrictive threshold. While there is some variation in the number for the threshold, 7 g/dL is an agreed upon value for asymptomatic healthy patients. Multiple studies have shown that this is an acceptable threshold in other patient populations as well, including in those with GI bleeding as well as in critically ill patients. The guidelines and clinical trials on transfusion requirements in critical care (TRICC) also recommend a value of 7 g/dl as the threshold for patients who are critically ill.

Transfusion may also be indicated in patients with active or acute bleeding as well as in patients with symptoms related to anemia (for example, tachycardia, weakness, dyspnea on exertion) and hgb less than 8 g/dL.

Unless the patient is actively bleeding, it is recommended to transfuse 1 unit of PRBC at a time, which will typically increase the hgb value by 1 g/dL and hematocrit by 3%. Follow up by checking post-transfusion hgb." (Lotterman, S., & Sharma, S., 2021)

The inpatient admission is considered medically necessary. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. This patient was on methotrexate, which causes anemia, but also had active GI bleed and an acute drop in her hgb with symptoms. This requires inpatient admission not observation level of care. 
                                                     
The insurer's denial of coverage for inpatient admission is overturned. Medical Necessity is substantiated.