Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia
Treatment: Inpatient Hospital Stay
The insurer denied the Innpatient Hospital Stay.
The determination is upheld.

This is a female patient with a past medical history of chronic anemia, hypertension, and gallbladder cancer, who was not undergoing active chemotherapy at the time of admission. She presented with anemia in her outpatient labs after having her blood drawn the previous day. A follow-up call was made as her hemoglobin level was noted to be 4.
The patient initially visited her primary care physician for screening labs for a new job but also reported feeling weaker than usual for the past couple of days and experiencing two syncopal episodes. The most recent syncopal episode occurred today and was accompanied by head trauma. It was unwitnessed and resulted in a residual left-sided headache. The patient denied any changes in vision, hearing, focal weakness, or numbness/tingling. She also mentioned experiencing intermittent non-exertional chest pain and shortness of breath, without palpitations, diaphoresis, or fever/chills. There were no reports of nausea, vomiting, diarrhea, cough, rashes, or changes in urination. Her last menstrual period occurred 4 days before her presentation and was described as having a normal flow. Additionally, the patient denied any dark or bloody stools.
An electrocardiogram was performed and showed sinus bradycardia with a heart rate of 55 beats per minute. Laboratory tests revealed a hemoglobin level of 8.6 and a hematocrit level of 29.1.
Based on the clinical findings, the patient was admitted to the hospital with a diagnosis of anemia and syncope. The admitting physician considered acute coronary syndrome to be unlikely, and there was no evidence of active bleeding. However, the patient ultimately chose to sign out against medical advice on the day of admission. At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
The patient presented to the hospital due to anemia and reported two syncopal episodes. Her hemoglobin level was not nearly as low as it was initially suspected, based on outpatient laboratory results. It was mentioned that the patient had chronic anemia at the baseline and there were no clinical signs of active bleeding. Another clinical diagnosis was syncope. The review of the medical records demonstrated that the patient had no signs of hemodynamic instability or severe or persistent altered mental status. There were no reports that the imaging studies demonstrated evidence of acute stroke, brain mass, or hydrocephalus. There was no indication that the syncopal episode was related to a pulmonary embolism, arterial dissection, acute congestive heart failure (CHF) exacerbation, acute blood loss anemia, or acute coronary syndrome.
There were no indications for an immediate electrophysiological study or other interventions such as automatic implantable cardioverter defibrillator (AICD) placement.
There was no evidence that the patient had a high degree of atrioventricular block, bradycardia with sinus pauses, or bursts of supraventricular tachycardia. The patient was only slightly bradycardic based on the electrocardiogram (EKG), however, the pulse rate was documented at 73 beats per minute (bpm). There was no evidence that the patient was severely dehydrated.
The review of the medical records revealed that the patient remained in stable clinical condition during the entire hospital stay, and did not require any treatment or testing that would justify admission at the acute inpatient level of care.
There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care with subsequent transition to outpatient care, rather than admission to an inpatient level of care.