Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Rectal Bleeding.
Treatment:  Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

This patient has a medical history of chronic constipation and irritable bowel syndrome.  He presented to the emergency department with rectal bleeding (described as three episodes of dark stool and melena, as well as red blood), cramping abdominal pain at 2/10 in intensity (noted as somewhat worse than baseline), weakness, and nausea after an esophagogastroduodenoscopy and colonoscopy earlier that day.  He had an esophagogastroduodenoscopy to investigate for Helicobacter pylori and celiac disease.  He had a colonoscopy for the indication of constipation, with finding of a few diminutive sigmoid colon polyps and polypectomy of a representative sigmoid colon polyp and a 2 millimeter (mm) rectal polyp; small internal hemorrhoids were also noted.  Vital signs were notable for an elevated systolic blood pressure of 146 millimeters of mercury (mm Hg).

The physical examination was notable for diffuse abdominal tenderness, black guaiac-positive stool, and bright red blood per rectum.  Lab results showed a normal blood count (including hemoglobin of 16.8 grams per deciliter (g/dL)) and unremarkable chemistry.  A chest x-ray showed no abnormality.  A computed tomography scan of the abdomen and pelvis showed no bowel obstruction, inflammation, or perforation.  He was made nil per os (NPO) and treated with intravenous fluids.  He had persistent epigastric pain and slight rectal bleeding.  Lab results showed a normal blood count (including hemoglobin of 15.3 grams per deciliter [g/dL]) and unremarkable chemistry.  A gastroenterology consultation noted that the bleeding had stopped, and vital signs and hemoglobin were stable, concluded that bleeding was likely post-polypectomy, and recommended advance diet as tolerated, monitor for further bleeding per rectum, and if no further bleeding and diet was tolerated, okay for discharge.  A gastrointestinal pathogen panel was positive for enterotoxigenic Escherichia coli.  He was feeling better other than minimal bleeding attributed to irritation; he had multiple episodes of diarrhea the prior day.  He was discharged.  At issue is the medical necessity for an inpatient stay.  The inpatient level of care is not medically necessary.

The patient presented with gastrointestinal bleeding and pain after an esophagogastroduodenoscopy and colonoscopy with polypectomy.  He was stable, with a normal blood count and normal hemodynamic status.  His blood count remained stable and the gastrointestinal bleeding declined.  The care provided, with monitoring, labs, intravenous fluids, and gastroenterology consultation, was appropriate to address post-polypectomy bleeding [1-4].  Testing revealed enterotoxigenic Escherichia coli, which was treated appropriately with supportive care [5].  There was no suspected or established complication such as hemodynamic decompensation, gastrointestinal perforation, intra-abdominal abscess, toxic megacolon, bowel obstruction, peritonitis, sepsis, or other complications warranting inpatient level of care [1-5].  The measures which were undertaken, such as observation, monitoring, labs, specialist consultations, and intravenous fluid administration could have been performed without the inpatient level of care.