Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vaginal bleeding and anemia
Issue under review: Inpatient admission 
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a woman, G2 P2, who presented to the emergency room with a ten-day history of heavy vaginal bleeding. She complained of recent weakness, dyspnea on exertion and faint feeling. Her pulse was 103, and blood pressure 166/77, with otherwise normal vital signs. Her past medical history was negative and surgical history was negative. Physical examination revealed normal findings except pale skin. A complete blood count (CBC) revealed a low hemoglobin/hematocrit (H&H) of 8/25. A transvaginal ultrasound revealed multiple uterine myomas with the largest measuring two centimeters (cm). A three-cm cervical mass was noted. 

Two units of blood were transfused. A gynecologic consult was obtained. The uterus was 12 weeks size on examination. The patient's last Pap was 13 years ago. The gynecologist suspected a prolapsing myoma as a cause, with some concern for a malignancy. 

The patient had normal vital signs and the H&H was 9.9/29.6. She had continued vaginal bleeding. The following day the patient had normal vital signs and the H&H was 9.7/28.9. She had continued vaginal bleeding. The gynecologist suspected a prolapsing myoma as a cause, with some concern for a malignancy. A cervical mass and submucous myoma were removed. The procedure was performed with no complications and minimal blood loss. The patient was discharged.

No, the proposed inpatient admission was not medically necessary.

The medical literature and medical records were thoroughly reviewed. Anovulatory uterine bleeding is defined as noncyclic menstrual blood flow that may range from spotty to excessive, is derived from the uterine endometrium, and is due to an anovulatory cause specifically excluding an anatomic lesion. Several terms have been used to describe anovulatory bleeding, including dysfunctional uterine bleeding (DUB). Several descriptive terms also are used to describe menstrual bleeding patterns, including menorrhagia, metrorrhagia, polymenorrhea, and menometrorrhagia. Menorrhagia, which more accurately describes this patient's condition, is defined as prolonged or excessive uterine bleeding that occurs at regular intervals. Diagnostic techniques to exclude anatomic pathology include physical examination supplemented by endometrial sampling, transvaginal ultrasonography as in this case, sonohysterography, hysterosalpingography, hysteroscopy, curettage, endometrial cultures, and timed tests for determining progesterone levels in serum. Anovulatory bleeding may be encountered as an acute or chronic condition. Patients with acute anovulatory bleeding may present as undergoing hemorrhage, and may exhibit hemodynamic changes. When acute abnormal vaginal bleeding is encountered estrogen treatment, based on the fact that estrogen in pharmacologic doses, causes rapid growth of the endometrium. This strategy is for the acute management of abnormal bleeding. The bleeding that results from most causes of DUB will respond to such therapy because a rapid growth of endometrial tissue occurs over the denuded and raw epithelial surfaces. To control an acute bleeding episode, the use of oral conjugated equine estrogen is a therapeutic regimen that has been found to be clinically useful. Acute bleeding from most causes is usually controlled, but if bleeding does not decrease within the first 24 hours, consideration must be given to an organic cause, and curettage be considered. 

However, the patient in this case was in the perimenopausal age range, increasing the likelihood of a malignancy causing the bleeding. Patients at this age range should undergo endometrial sampling and structural evaluation to rule out cervical and uterine malignancy. Symptomatic patients such as the one in this case may require intravenous (IV) hydration and/or blood transfusions, as in this case. 

The patient had symptomatic anemia from menorrhagia. The patient presented to the emergency room with heavy vaginal bleeding and was found to have symptomatic anemia. On admission to the emergency room the patient had tachycardia with dyspnea on exertion. Her physical and pelvic examinations were abnormal for pale conjunctivae and heavy vaginal bleeding. There was imaging evidence of a cervical mass. Therefore the hysteroscopic procedure and D&C were within the standard of care to perform. The patient was documented to have an improved H&H after the transfusion, which did not decrease over the next three days of hospitalization. The patient was stable throughout her stay. The interventions provided, transfusion, could have been provided in a lower level of care. In addition, given her stable intraoperative condition and uncomplicated postoperative recovery she could have been treated at lesser level of care, rather than as an acute inpatient admission. Therefore the treatment was within the standard of care to be provided in a less than acute level of care setting, and not in an inpatient setting. Therefore the services were not medically necessary.