Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Prostate Cancer
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

This patient is an adult male with prostate cancer status post radiation last year, alcohol (EtOH) cirrhosis with grade 1 esophageal varices in the lower third of the esophagus, 
splenomegaly, iron deficiency anemia, hypertension, sleep apnea, gout, and Parkinson's disease. Per the appeal letter, the patient presented to the hospital for lower extremity edema, weakness, and rectal bleeding. The patient previously had a colonoscopy the month before which showed a single diverticulum with friable spontaneous bleeding that was treated with argon plasma coagulation (APC). The colonoscopy also showed internal hemorrhoids. The patient was transferred to the hospital for further care due to his persistent rectal bleeding with plan for capsule endoscopy. The patient was on Sandostatin and 
Protonix drips prior to the transfer with emergency medical services (EMS). The patient presented with bradycardia to 47. He was made nothing by mouth (NPO) with intravenous fluids on hold due to having fluid overload. He required intravenous Protonix 40 milligrams and twice daily Carafate. He had complete blood count (CBC) every 12 hours. He received intravenous ceftriaxone, Flagyl, and Zosyn and pain management with Baclofen 10 milligrams twice a day, Belbuca 900 micrograms film buccally every 12 hours, and Dilaudid 4 
milligrams every 6 hours as needed with plan for pain management consult. The patient underwent sigmoidoscopy showing radiation proctitis status post argon plasma coagulation. A capsule endoscopy exam was initiated. On day #2/, labs were notable for worsening hyponatremia (132), hypomagnesemia (1.4), and hemoglobin and hematocrit were 8.8/27.5. An abdominal x-ray was done noting video capsule in the gastric antrium. Esophagogastroduodenoscopy showed multiple angioectasias in the stomach status post argon plasma coagulation. On day #3, the patient had persistent hypomagnesemia to 1.4. Urine analysis showed large blood. He had 10 out of 10 generalized abdominal pain requiring Dilaudid. He underwent double-balloon enterosopy with ''scarred mucosa in the gastric body and antrum representing prior AVM which was treated with APC and had friable duodenal mucosa and friable jejunal mucosa." On day #4, the patient had persistent hypomagnesemia to 1.3 requiring ongoing repletion with intravenous magnesium sulfate. Later in the evening, the patient had another episode of blood in stool and in urine. On day #5, the patient had another episode of bloody bowel movement, multiple episodes of bradycardia to the 40s, tachycardia to 121, and episodes of hypotension to 80s/40s. Labs were notable for persistent hypomagnesemia times 2 to 1.5 requiring intravenous magnesium sulfate 2 grams times 2 doses. He also had leukocytosis to 11.9. He had positive orthostatic blood pressures that dropped when laying. On day #6, the patient began spiking fevers to 102.9 and had leukocytosis to 14.1. On day #7, labs were notable for anemia with a drop in hemoglobin to 8.6 and hematocrit to 27 (from 10.4 / 32.4). Abdominal ultrasound was done to evaluate for cholecystitis revealing ''hepatic cirrhosis, gallbladder wall edema." Hematology/Oncology evaluated the patient. He was seen by colorectal surgery. On day #8, the patient had low magnesium to 1.5 requiring two doses of intravenous magnesium sulfate 2 grams. He had worsening anemia to hemoglobin of 7.6 and hematocrit of 23.1. On day #9, the patient had a temperature spike to 100.8 and low magnesium of 1.5. On day #10 to day #11, he was followed by Gastroenterology and was noted to have small bowel movements with blood and clot. Carafate enemas were used. The patient was discharged on day #12.

The proposed treatment was medically necessary.

The patient required an inpatient level of care given ongoing rectal bleeding throughout the hospital stay requiring close monitoring of vital signs and blood counts and necessitating multiple interventions (sigmoidoscopy, esophagogastroduodenoscopy, capsule endoscopy). The 
patient required a multidisciplinary team (gastrointestinal, colorectal surgery). The patient had hemodynamic instability with shifts in heart rate and fevers. The patient also had electrolyte derangement necessitating intravenous replacement. Therefore, the proposed treatment was medically necessary.