Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anemia.
Treatment: Full Hospital Admission.
The insurer denied the full hospital admission.
The health plan's determination is overturned.

The patient is a female who was admitted to the hospital with fatigue and black stools. The patient is not on anticoagulation Aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs). The last colonoscopy was two years before this presentation and it was reportedly unremarkable. Her admission hemoglobin was 4.6 grams per deciliter (g/dL). She denied hematemesis. The patient's temperature was normal, her heart rate was 89 and her blood pressure was 94/42. The patient appeared tired and chronically ill on examination with a normal cardiopulmonary exam. The patient's abdomen was soft and nontender.

The laboratory studies were otherwise remarkable for a blood urea nitrogen (BUN) of 49, a creatinine of 1.2, and normal potassium and sodium levels. Her lactic acid was 1 and her lipase was normal. The platelet count was 159.

The computed tomography (CT) of the abdomen showed no acute abdominal or pelvic pathology. The chest x-ray was also remarkably normal. The patient was admitted to the hospital with symptomatic anemia and gastrointestinal (GI) bleeding and was treated with two units of packed red blood cells in the emergency department. She was started on Protonix, placed on a clear liquid diet, and gastroenterology was consulted for an endoscopy procedure.

The gastroenterologist assessed the patient, and it was revealed that she had never had an upper endoscopy completed. She was scheduled for both an esophagogastroduodenoscopy (EGD) and a colonoscopy two days after the admission. The next day, the patient's hemoglobin was 6.3, and an additional unit of blood was transfused to improve the hemoglobin to 7 g/dL. The bowel prep was started on this day for the anticipated EGD and colonoscopy.

The EGD showed gastritis with possible esophageal varices but they were nonbleeding. The colonoscopy showed a 10 millimeter (mm) polyp in the ascending colon, which was removed. There were also hemorrhoids present. The gastroenterologist recommended an outpatient capsule endoscopy.

The patient remained in the hospital and when she was reassessed by the gastroenterologist, she reported additional information about non-alcoholic steatohepatitis (NASH) documented by her primary care physician. The gastroenterology team ordered a right upper quadrant ultrasound and autoimmune laboratory studies for liver disease. The patient's vital signs remained stable. Later in the afternoon, the right upper quadrant ultrasound showed cholelithiasis and gallbladder wall thickening, raising the concern for acute cholecystitis. Surgery was asked to assess the patient. The patient's hemoglobin was 7.2. She felt generally improved. She developed one febrile episode with a temperature of 101.2 during the third blood transfusion, possibly a transfusion reaction. She did not appear septic.

The health service/treatment of a full hospital admission was medically necessary. The patient presented with symptomatic anemia due to GI bleed, with profoundly low hemoglobin of 4.6 g/dL and hypotension. This is an indication for inpatient admission based on guidelines for treating the upper GI bleed. The endoscopic evaluation revealed potential sources of bleeding, in the upper GI tract, including gastritis and varices, which were not actively bleeding at the endoscopic evaluation. The patient's hemoglobin did not gradually improve to greater than seven g/dL with the initial infusion of two units of packed red blood cells. She required another unit of blood, during which time she experienced fevers. It was reasonable and medically necessary to monitor this patient in an inpatient setting due to the severity of the presentation. A greater than 48-hour hospital stay is expected for such a presentation, qualifying her for inpatient care.

The health plans determination of medical necessity is overturned in whole.