Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hemodynamic instability and symptomatic anemia.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned. 

This is a female patient with irritable bowel syndrome (IBS), varices, and alcohol abuse. The patient was sent to the Emergency Room (ER) by her physician for blood transfusion. In the ER, the patient was noted to have a systolic blood pressure (SBP) of 80, heart rate (HR) over 100, and hemoglobin of 6.6. The patient was given intravenous (IV) fluids and Protonix, and was admitted to the hospital. The patient was transfused and discharged the following day.

Per Long and Koyfman (2018), "Anemia is commonly found on laboratory evaluation and is due to decreased red blood cells or hemoglobin concentration... Transfusion considerations include assessment of patient hemodynamics. Unstable patients with anemia require transfusion. A transfusion threshold of 7 g/dL [grams per deciliter] is recommended for patients with sepsis, trauma, critical illness, and gastrointestinal bleeding. Iron is an alternative treatment for patients with microcytic anemia owing to iron deficiency, and hyperbaric oxygen therapy is another option if available."

Per Carson et al. (2016), "It is good practice to consider the hemoglobin level, the overall clinical context, patient preferences, and alternative therapies when making transfusion decisions regarding an individual patient. Recommendation 1: a restrictive [red blood cell (RBC)] transfusion threshold in which the transfusion is not indicated until the hemoglobin level is 7 g/dL is recommended for hospitalized adult patients who are hemodynamically stable, including critically ill patients, rather than when the hemoglobin level is 10 g/dL (strong recommendation, moderate quality evidence). A restrictive RBC transfusion threshold of 8 g/dL is recommended for patients undergoing orthopedic surgery, cardiac surgery, and those with preexisting cardiovascular disease (strong recommendation, moderate quality evidence). The restrictive transfusion threshold of 7 g/dL is likely comparable with 8 g/dL, but [randomized controlled trial (RCT)] evidence is not available for all patient categories. These recommendations do not apply to patients with acute coronary syndrome, severe thrombocytopenia (patients treated for hematological or oncological reasons who are at risk of bleeding), and chronic transfusion dependent anemia (not recommended due to insufficient evidence). Recommendation 2: patients, including neonates, should receive RBC units selected at any point within their licensed dating period (standard issue) rather than limiting patients to transfusion of only fresh (storage length: <10 days) RBC units (strong recommendation, moderate quality evidence)."

As per Milliman Care Guidelines (MCG) guidelines for Anemia, Iron Deficiency or Unspecified, clinical indication for admission includes: (1) Hemodynamic instability as indicated by vital sign abnormality not readily corrected by appropriate treatment (i.e., hypotension that persists despite appropriate treatment, e.g., volume repletion, treatment of underlying cause); (2) Active hemolysis (e.g., progressive anemia).                    

In this case, this patient presented with hemodynamic instability warranting admission. The patient met criteria for inpatient admission at the time of presentation due to symptomatic anemia with hemoglobin of 6.6 and unstable vital signs. As per MCG guidelines, this patient's anemia was associated with hemodynamic instability that warranted an inpatient level of care. 

The inpatient hospital admission would be considered medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient.      

The medical necessity for the inpatient hospital admission is substantiated. The insurer's denial should be overturned.