Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectal bleeding

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld. 

According to the documentation submitted, this is a patient with a history of cerebrovascular accident (CVA), Parkinson's, hyperlipidemia (HLD) and status-post hemorrhoidectomy.  As per the emergency department (ED) provider note, the patient presented with rectal bleeding. The patient had clotted blood in their diaper and felt rectal pain. The patient denied chest pain, shortness of breath, nausea and vomiting. Vital signs were stable. Exam revealed abdomen to be soft, non-distended, non-tender with dark red blood in the diaper and no active hemorrhage noted. The plan was to consult colorectal for further recommendations.

The patient was admitted to surgery. The note indicated the patient was hemodynamically stable. Rectal exam was notable for stool/melena. Anoscopy did not visualize any active bleeding. The patient denied chest pain, shortness of breath and tachycardia. Hemoglobin (Hgb) was 12.6, platelet count was 164 and international normalized ratio (INR) was normal. The patient was made nothing by mouth (NPO) and given intravenous (IV) fluid.

The patient was taken to the operating room and as per the operative report the patient underwent anorectal exam under anesthesia, right procto-anoscopy, and suture ligation of bleeding hemorrhoid with estimated blood loss (EBL) of 5 milliliters (mL). Progress notes on indicated the patient was doing well with stable vital signs and no overt rectal bleeding. The plan was for discharge.

At issue the insurer has denied coverage for inpatient admission. In their Final Adverse Determination letter, they stated that they are upholding their denial decision. They noted the patient came to the ED and was admitted for rectal bleeding. To approve this service, the following criteria, must be met: the health data sent did not meet the guide they use called Milliman Care Guidelines (MCG) criteria. Specifically an inpatient admission was not medically necessary because the patient did not have the following: abnormal vital signs; ongoing active bleeding (decrease hematocrit); failure to control bleeding after colonoscopy; coagulopathy; suspected or known ischemic colitis; etc. These criteria are not met because: a review of the records shows that the patient could have been managed in a lower level of care (observation), where the patient could be treated for symptoms and observed for response to treatment. This decision was made under 42CFR sections 438.210 and 438.404; NYS social services law section 364-j (4) (k) and 365-a (2); NYCRR, section 360-10.8; 18 NYCRR 505.4; and 18 NYCRR 533.1.

According to according to MCG Health General Recovery Guidelines 27th Edition General Surgery or Procedure GRG: SG-GS (ISC GRG), Operative Status Criteria is ambulatory for many procedures. Examples include: Endoscopic procedures; Embolization procedures; Most biopsy procedures; Many elective operations; etc.  In this case the patient should have been managed as an outpatient without acute inpatient hospitalization as the patient should have had the ligation of the bleeding hemorrhoid without an acute inpatient admission. The patient was hemodynamically stable throughout and did not need an acute admission but rather observation. 

Finally, MCG Health noted in General recovery care 27th edition General admission criteria GRG: CG-GAC (ISC GRG) that admission is indicated for 1 or more of the following: Hemodynamic instability; Acute peripheral ischemia (e.g. pulseless, cool, mottled, or cyanotic extremity; Cardiac arrhythmias of immediate concern;  Severe respiratory findings; Severe airflow or ventilation abnormalities; etc.  Based upon these guidelines this patient should have been observed rather than placed in an acute admission as the patient did have any indication as noted above for inpatient stay. All that was needed was observation and not acute admission.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is not substantiated.