Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vaginal Bleeding. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is overturned. 

The patient presented to the hospital with complaints of vaginal bleeding. She reported changing three pads per hour and passing blood clots. This was associated with abdominal cramps and dizziness. It was reported that the patient had been diagnosed with a pulmonary embolism approximately a month and a half prior and was treated with Eliquis. It was also reported that the patient was hospitalized for vaginal bleeding and Eliquis was held. At that time, interventional radiology was consulted for possible uterine artery embolization, however this procedure was not recommended. 
At that time, the patient underwent a hysteroscopy, dilation and curettage (D&C), myomectomy, and insertion of Mirena intrauterine device (IUD). The vaginal bleeding improved and the patient resumed treatment with Eliquis. Laboratory evaluation revealed that the white blood cell count was 10.9, hemoglobin 11.4, hematocrit 37.4, and platelets 363.  The international normalized ratio (INR) was 1.05. 
During the hospital stay, the patient was seen by a pulmonologist who recommended that the patient had no clinical signs of venous thromboembolism. 
The pulmonologist recommended holding the direct Oral anticoagulant (DOAC). Interventional radiology recommended a transvaginal ultrasound or magnetic resonance imaging (MRI) of the pelvis to determine the need for possible intervention. 
As a result of holding the DOAC (Eliquis), the vaginal bleeding significantly improved. 
Subsequently, it was decided that the patient could not be discharged on Eliquis without proper intervention due to the high risk of recurrence of vaginal bleeding. At the same time, she could not be off the DOAC due to a recent venous thromboembolism. The main clinical issue was if uterine artery embolization could be a viable option to control the bleeding, otherwise, a hysterectomy was thought to be an alternative. After further discussion, the decision was made to proceed with uterine artery embolization. 

At issue is the medical necessity of an inpatient stay. 

The inpatient stay was medically necessary for this patient. This was a very complicated clinical case, since the patient developed vaginal bleeding while being on anticoagulation due to a recent venous thromboembolism. Discontinuation of anticoagulation definitely helped with the bleeding, but was not a viable option because of the high risk of venous thromboembolism. 
Therefore, the complexity of this clinical case required decisions and interventions that could not be performed within a reasonable time frame acceptable at a lower level of care. 
Despite the discontinuation of anticoagulation, the patient continued to have vaginal bleeding and her hemoglobin and hematocrit (H&H) was drifting down. 
Taking into consideration all of this information, the complexity of the clinical situation, including the establishment of the strategy, justified admission at the acute inpatient level of care. 

The Milliman Care Guidelines (MCG) 25th Edition Obstetric and Gynecologic Disease General Recovery Guidelines (GRG) criteria were reviewed. According to the criteria, admission at the acute inpatient level of care was justified for uterine bleeding with high-risk features that included coagulopathy. 

The complexity of the clinical situation completely justified admission at the acute inpatient level of care for the patient who presented with uterine bleeding in the setting of coagulopathy, in addition to the fact that the patient needed anticoagulation due to the recent venous thromboembolism.