Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Symptomatic anemia

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld.

This is a female patient whose past medical history includes hypertension as well as hyperlipidemia, chronic kidney disease (CKD), diabetes, hypothyroidism and a prior history of neuroendocrine tumor status post distal pancreatectomy. She presented to the Emergency Department (ED) with complaints of nausea as well as vomiting and diarrhea.  

On ED presentation, the patient reported that the prior day, she had 8 episodes of diarrhea. She also complained of lower abdominal pain and nausea. The physical examination revealed a heart rate of 71 beats per minute with a temperature 97.6 degrees.  The patient's oxygen saturation was 100% and her blood pressure was 176/71. The patient was chronically ill-appearing. The patient was recommended to undergo multiple laboratory diagnostic studies. Her laboratory results revealed a creatinine of 4.6 with osmolality of 314. Her glomerular filtration rate (GFR) was noted to be 10.23. The patient's troponin was negative, and her white blood cell (WBC) count was 12.7. The patient's red blood cells were 2.2 with hemoglobin of 6.7 and hematocrit of 29.5. 

The patient underwent a computed tomography (CT) scan showing small, right greater than left, pleural effusions with bibasilar atelectasis. Her kidneys were unremarkable.  Electromagnetic radiation (x-ray) imaging of the patient's chest showed trace pleural effusions with bibasilar atelectasis without significant change. There was no new regional consolidation. The documentation indicated that upon reexamination, it was noted that her hemoglobin decreased to 6.7 from 9.5 (which was noted from a previous admission earlier that month). The patient also had a positive guaiac test, and it was recommended that she be admitted for symptomatic anemia. The patient was recommended to undergo a transfusion of 2 units of packed red blood cells. The documentation detailed that the patient was admitted for further evaluation and management, and was started on oral vancomycin. The patient's post-transfusion labs showed hemoglobin increased to 8.6. She was also evaluated by gastroenterology as well as nephrology. The patient was recommended during her inpatient stay to discuss hemodialysis; however, she did not wish to initiate hemodialysis as an inpatient.  She continued with treatment and slowly improved. There were no significant adverse events during the entire hospital stay. She was discharged on day 7 of admission with instruction to follow-up as outpatient.

Based on the review of the medical record and literature, there is no medical indication that the patient could not have been managed in the observation setting. The patient has a history of progressive CKD that was at stage 5, presumed secondary to diabetic nephropathy and hypertension. She was found to have a serum creatinine level of 4.6 on admission (which was better than her previous creatinine level) and vague uremic symptoms. Transfusion does not require acute inpatient management. The patient refused dialysis initiation during this hospitalization.  Nephrology care provided upon review of the records did not require an inpatient level of care and could have been appropriately cared for in the observational level of care. Thus, inpatient admission was not medically necessary for this patient.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission should be upheld. The medical necessity is not substantiated.