Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bleeding From The Lower Bowel
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female. She has a history of an open abdominal aortic aneurysm repair with an aorto-bi-femoral graft. She subsequently developed occlusion of the left limb of the graft and had undergone a femoral -femoral bypass seven days prior to this admission and had resumed Xarelto three days prior to her presentation in Emergency. She notes four to five episodes of bright red blood on the paper with bowel movements as well as lower abdominal post-surgical pain. Her past history is positive for colon cancer five years prior treated with chemoradiation and surgery.

On arrival in Emergency the patient was noted to be afebrile, mildly tachycardic but with a stable BP (blood pressure). She received IV (intravenous) fluids, and late afternoon she was feeling better, ambulating and deemed ready for discharge. In the triage area she felt lightheaded with a BP (blood pressure) of 79/53 and was returned to the Emergency Room for further care. Her Hgb (hemoglobin) was 8.2 with an INR (international normalized ratio) of 1.0 on admission and 7.4 on repeat draw.

One unit of red blood cells was given. A CT (computed tomography) scan was consistent with post-surgical changes, and no acute process was seen. The patient was seen in the ED (emergency department) by Vascular Surgery and cleared for discharge. She was seen in consultation by Colorectal Surgery, who noted enlarged hemorrhoids with no active bleeding on exam and recommended proprietary treatment with out-patient follow-up. GI (gastroenterology) consultation was confirmatory.

The patient was admitted to acute in-patient status. She was provided with supportive care. She was found to be hemodynamically stable with no further bleeding while in the hospital, and she was discharged to be followed in clinic.

No, the Inpatient admission was not medically necessary.

A review of the medical records provided document that the patient presented to the Emergency Department with rectal bleeding for-several days following resumption of anti-coagulation therapy after a recent vascular surgery. The bleeding is noted to be blood on the tissue paper associated with BM (bowel movement) and felt to be secondary to the patient's known history of hemorrhoidal disease. There is no documentation of a significant lower GI (gastrointestinal) bleed with frequent passage of blood and clots per rectum prior to her arrival and no documentation of rectal hemorrhage or hemodynamic instability while receiving care. While she did experience some transitory dizziness in the Emergency Department and was noted to have an anemia most likely secondary to her recent surgery, both of these issues were managed appropriately prior to her admission to acute in-patient status. Further work-up failed to reveal any additional abnormalities that required treatment. Consultations with Vascular Surgery, Colorectal Surgery and GI (gastroenterology) all deemed the patient suitable for discharge with out-patient follow-up. Nursing notes also reflect that on several occasions prior to admission, the patient herself noted that she felt fine and wished to be allowed to go home. The severity of her illness and the treatment rendered do not rise to the level of acute in-patient care and are, therefore, not medically necessary.

The care received by the patient could have been rendered at a lower level of care, with appropriate follow-up on an outpatient basis. The severity of her symptoms and the treatment provided did not require admission to the hospital. The health plan's determination in this case is reasonable and consistent with the standard of care and thus serves the best interest of the patient.