Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Anemia
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

This is an adult male with a history of alcohol abuse, tobacco abuse, and alcoholic liver cirrhosis. The patient presented to the emergency room (ER) and was found to be anemic. He reported intermittent rectal bleeding, bleeding when he urinates, and anal fissures. He received a transfusion due to low hemoglobin (Hgb) level. His Hgb level improved from 6.3 to 8.8. The patient was discharged after a period of hemodynamic stability. The anal bleeding was not severe or new. Per the note, there was no dizziness, weakness, or loss of consciousness (LOC).

The patient had a lack of symptoms related to the low Hgb (he was referred by an outside physician), based on the response and condition of the patient, it suggested chronic anemia. The patient did not need to be admitted as an inpatient, observation would have been appropriate to ensure Hgb remained stable. The patient was going to be discharged from the ER and then he was admitted. The documentation does not support or provide an indication as to why the patient was admitted. The patient had no pain, and assessments were the same, no changes. The patient was alert and oriented, so no change in neurological status.      

"...anemia often is multifactorial, commonly resulting from bleeding, repeated phlebotomy, and blunted erythropoiesis associated with acute illness. The rationale for treating anemia has been based on 2 lines of evidence. Anemia has been believed to be physiologically deleterious, requiring a compensatory increase in cardiac output to maintain systemic oxygen delivery. Furthermore, anemia has been associated with a poorer prognosis for various conditions, including cancer, chronic kidney disease, and congestive heart failure. Thus, it has been assumed that anemia warrants correction, especially in older patients with cardiovascular disease, despite limited evidence showing benefit. However, randomized clinical trial data show that less frequent red blood cell (RBC) transfusion is safe in hospitalized patients with moderate anemia. The results of these clinical trials are the basis for patient blood management programs that emphasize pre-perioperative optimization of hemoglobin levels but also tolerance of progressive degrees of anemia. In our cohort, these perioperative strategies seem to have reduced the number of elective surgical patients discharged with moderate anemia. Conversely, changes in clinical practice have resulted in an increase in medical and nonelective surgical patients being discharged with moderate anemia." (Roubinian et al., 2019)

The patient presented on the request of his gastroenterologist for low hemoglobin. He denied any dizziness, chest pain, shortness of breath, and abdominal pain. The patient had known anal fissures and hemorrhoids, and intermittent blood in stool. He needed a transfusion, which can be performed as outpatient or as an observational status. In this case as the patient was needing three units of packed red blood cells, observational status would have been the most appropriate level of care.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.