Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blood Disorder/Anemia.
Treatment: Inpatient Admission.

The health plan denied the requested inpatient admission as not medically necessary. 
The health plan's determination is upheld.

The patient is a female with a past medical history significant for obesity, menorrhagia, and anemia who presented to the hospital with complaints of shortness of breath and bilateral leg heaviness.

The patient reported that over the course of 2 months she had shortness of breath, headaches, fatigue, and malaise. The laboratory evaluation that was performed by her primary care physician (PCP) revealed anemia. It was mentioned that 3 months before the presentation her hemoglobin was 7.0. The most recent blood work performed by her PCP revealed worsening anemia with hemoglobin 4.5. Therefore, she was instructed to come to the hospital.

At the time of the initial evaluation in the emergency department, the patient denied any bleeding. 

When seen by the admitting physician, the patient was afebrile. Her blood pressure was 138/81 millimeters of mercury (mmHg), with a pulse rate of 117 beats per minute (bpm), a respiratory rate of 18 breaths/min, and an oxygen saturation of 100%. On exam, the patient was tachycardic. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. The rest of the physical exam was unremarkable.
Laboratory evaluation revealed that white blood cell count was 10.0, with a hemoglobin of 4.6, a hematocrit of 118.2, platelets of 562, a sodium of 137, a potassium of 4.4, a chloride of 104, a bicarbonate of 24, a blood urea nitrogen (BUN) of 9.0, a creatinine of 0.8, and a glucose of 82. Liver function tests were unremarkable.
The patient was admitted to the hospital with microscopic anemia, which was attributed to menorrhagia. She received a transfusion of one unit of packed red blood cells. A computed tomography (CT) scan of the abdomen and pelvis showed no evidence of hepatic splenomegaly, biliary dilatation, or enlarged lymph nodes. There was an enlarged lobulated uterus likely due to myomatous changes. The rest of the study was unremarkable.

During the hospital stay, the patient was transfused a total of 3 units of packed red blood cells, and her hemoglobin went up to 7.6. The patient also received intravenous iron supplements. The patient was seen by a hematologist, who diagnosed the patient with microscopic anemia and thrombocytosis. It was determined that the patient's anemia was most consistent with iron deficiency anemia. During the hospital stay, the patient remained hemodynamically stable.

The patient was discharged from the hospital with a recommendation to follow up with a hematologist, and obstetrics/gynecology as an outpatient.

I uphold, in whole, the health plan's determination of medical necessity.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.

The patient presented to the hospital with microfluidic anemia most likely due to menorrhagia; however, there was no evidence that the anemia was associated with hemodynamic instability, active bleeding, or hemolysis.

The anemia was not associated with altered mental status, recurrent syncopal, or near syncopal episodes. There was no evidence of high-risk low platelet count.
The anemia was not associated with acute renal failure, heart failure, myocardial ischemia, acute peripheral ischemia, or any other signs or symptoms requiring intervention at the acute inpatient level of care.

Overall, the patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.

The admission at an alternate level of care would have been justified to ensure stability, transfuse blood, and perform an anemia work-up.