Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blood Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a female with a past medical history significant for hypertension, uterine fibroid, iron deficiency anemia, menorrhagia, bilateral deep vein thromboses (DVTs), and a history of inferior vena cava (IVC) filter placement who presented to the emergency department with abnormal laboratory results. The patient underwent routine blood work that revealed anemia. The patient's hemoglobin was 6.9, therefore she was instructed to come to the emergency department.

The patient was in no acute distress. She was awake, alert, and oriented times three. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The neurologic exam was unremarkable.
Laboratory evaluation revealed that white blood cell count was 6.2, hemoglobin was 6.9, hematocrit was 24.6, and platelets were 304.
Sodium was 138, potassium was 4.0, chloride was 106, bicarbonate (HCO3) was 26, blood urea nitrogen (BUN) was 10, creatinine was 0.64, and glucose was 99. Arterial blood gas (ABG) results were unremarkable.
The patient was admitted to the hospital with microcytic anemia. It was suspected that the patient had iron deficiency anemia due to prolonged menses in the setting of uterine fibrosis.
The patient was evaluated by a hematologist who recommended intravenous iron infusion as well as transfusion of an additional unit of packed red blood cells.
During the hospital stay, the patient remained afebrile and hemodynamically stable. Her hemoglobin and hematocrit (H&H) levels rose following transfusion of packed red blood cells; therefore, the patient was discharged home in stable clinical condition.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

According to the nationally accepted standards of care, the acute inpatient level of care is usually required for patients with anemia and hemodynamic instability, active hemolysis, active bleeding that could not be controlled in the emergency department or during the period of observation, also in cases of severe or persistent altered mental status, recurrent syncope or near syncope episodes, cardiac arrhythmias of immediate concern, acute peripheral ischemia, high-risk low platelet count, acute renal failure, clinically significant symptoms such as heart failure, chest pain, myocardial ischemia, persistent dyspnea.
The review of the medical records clearly demonstrated that the patient had none of these circumstances.
Considering the fact that the patient presented with anemia being on anticoagulation, it was reasonable to admit the patient for monitoring to ensure clinical stability and decide about the continuation of treatment with blood thinners.
However, neither the severity of the patient's condition nor the complexity of the services provided rose to the acute inpatient level of care.
There was no compelling clinical reason why the patient could not have safely and appropriately been treated at a lower level of care status. Overall, she remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.