Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain and vaginal bleeding
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The Inpatient admission was not medically necessary, because the care rendered could have been performed at a lower level of care (observation level) without adversely affecting the patient's health. 

The patient is a female. She presented at the Emergency Department (ED) with complaints of cough, vomiting, shortness of breath and chest tightness and excessive vaginal bleeding, associated with passing blood clots. Her past medical history is significant for obesity (BMI 45.0 kg/m2), two prior pregnancy terminations and two prior cesarean sections.

The patient's vitals were as follows: Blood pressure 118/66, pulse 96 BPM (beats per minute), temperature 98.6F, respiratory rate 18, and oxygen saturation 98%.  Her physical examination was unremarkable.

The patient's labs were as follows: White cell count 8.1, hemoglobin 7.6 g/d, hematocrit of 26.9%, platelets 399, sodium 143, potassium 3.9, and creatinine 0.76 mg/Dl.  Troponin was negative. EKG (electrocardiogram) showed sinus rhythm at 81 BPM. Chest x-ray did not show any acute cardiopulmonary disease.  Pelvic ultrasound showed small echogenic foci in the Cervix, which may represent calcifications or air. 

Assessment was acute coronary syndrome (it was noted that the patient has chest heaviness for one and half weeks, and EKG findings of sinus arrhythmia with T-wave abnormality), dysfunctional uterine bleeding, morbid obesity, dyspepsia menorrhagia and symptomatic anemia. She was admitted to inpatient.  Plan was to monitor in telemetry and follow serial EKG/troponins, transfuse 1-unit PRBC (packed red blood cells), monitor hemoglobin/hematocrit and consult obstetrics and gynecologist.

Cardiology/gynecologist consult were completed.  Discharge diagnoses were dysfunctional uterine bleeding and symptomatic anemia. The patient was discharged home the next day.

Depending on the clinical condition, anemic patients can be placed in observation care level, inpatient medical floor, or intensive care unit (ICU). Most patients with chronic anemia may not be admitted to inpatient status, unless they have severe complications, including hemodynamic instability, respiratory compromise, active bleeding, that cannot be controlled, persistent altered mental status, or other life-threatening events for example sepsis.  The patient had evidence of symptomatic anemia on admission; her hemoglobin level was low requiring transfusion of one unit of PRBC ordered in the emergency room.  However, she was hemodynamically stable on admission.  There was no evidence of low blood pressure requiring vasopressor. There were no signs of acute heart failure, change in mental status, acute respiratory failure or persistent active hemorrhage that was uncontrolled. Further, she had no evidence of significant electrolyte imbalance, severe enough to warrant inpatient admission. Diagnosis of acute coronary syndrome was noted; however, there was no documentation of elevated cardiac enzymes or that she required cardiovascular intervention while on admission.

Hence, the proposed treatment is not medically necessary, because the care rendered could have been performed at a lower level of care without adversely affecting the patient's health.