Appeal type: Medical necessity
Decision: Overturned

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

The patient has a medical history of anemia, migraine, nephrolithiasis, gastroesophageal reflux disease (GERD), and asthma. She presented to the emergency department with rectal bleeding characterized by melena, multiple episodes of diarrhea, and lightheadedness since the prior night. She reported dizziness and had low blood pressure in the 50s/30s; she was transferred to the crash area of the emergency department and 2 units of blood were ordered. Her vital signs were unremarkable on presentation.
The physical examination was notable for right costovertebral angle tenderness, lack of abdominal tenderness, and lack of abdominal guarding. Lab results showed an elevated white blood cell count of 11.3 thousand per microliter (K/uL), and an otherwise unremarkable complete blood count. A computed tomography scan of the abdomen and pelvis with angiogram showed hepatic steatosis; no hepatosplenomegaly, lymphadenopathy, or ascites; normal kidneys, colonic diverticulosis without colitis or diverticulitis, and no evidence of gastrointestinal bleeding. She was treated with intravenous pantoprazole. She was made nil per os. She was transfused with 2 units of packed red blood cells. A gastroenterology consultation noted melena in the setting of Naproxen use, and hypotension but a normal hemoglobin; the recommendation was esophagogastroduodenoscopy that day, nil per os, continue intravenous fluids, and continue blood transfusion. An esophagogastroduodenoscopy showed a non-obstructing Schatzki's ring in the distal esophagus, 3 centimeter (cm) hiatal hernia, no active bleeding or old blood in the visualized stomach, mild non-bleeding erythema in the proximal gastric body, and edematous and erythematous pre-pyloric folds.
She had no complaints, and was transferred to the regular medicine floor. Lab results showed a normal hemoglobin and low hematocrit of 34.7 percent (%). A colonoscopy showed moderate diverticulosis throughout the entire colon, small (Grade I) internal hemorrhoids, no active bleeding or sequela eating, normal terminal ileum, and likely diverticular bleeding given acute onset and resolution; the recommendation was no need for intensive care from a gastrointestinal perspective, advance diet as tolerated, and a high-fiber diet. She was in no acute distress, and she had no further bleeding or bowel movements. Lab results showed a normal hemoglobin and low hematocrit of 36.2%, low platelets of 174 K/uL, elevated aspartate aminotransferase of 40 units per liter (U/L), and elevated alanine aminotransferase of 35 U/L. She was reported to be clinically improved, with no further bleeding and a stable hemoglobin. She was discharged on docusate, pantoprazole, and Senna, with a plan for primary care and gastroenterology follow-up. At issue is the medical necessity for the inpatient level of care.

The inpatient level of care was medically necessary. The patient presented with melena and then had severe hypotension after presentation, requiring rapid transfusion. The patient had close monitoring, which was warranted as bleeding can be severe and sudden in onset [1-6]. She appropriately underwent an urgent esophagogastroduodenoscopy and then a colonoscopy. She had a good response to the transfusion, and her blood count remained stable. Given the severity of her symptomatic hypotension, and the potential for rapid bleeding from an unknown source with recurrent hemodynamic instability, the inpatient level of care was supported in this case. Per the Milliman Care Guidelines for Gastrointestinal Bleeding, Lower, the inpatient level of care is supported: Hemodynamic instability (MET - very low blood pressure which required immediate transfusion). [7]