Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastrointestinal bleeding. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is overturned. 

According to the documentation submitted, this is an adult with a history of Von Willebrand's Disease, gastrointestinal angiodysplasia, external hemorrhoids, chronic gastrointestinal bleeding, mitral valve prolapse, seborrheic dermatitis, and vestibular migraines. The patient presented to the emergency room (ER) with complaints of dizziness and a recent gastrointestinal bleed. During the admission the patient underwent a blood transfusion, colonoscopy, and esophagogastroduodenoscopy (EGD). The patient underwent a hemorrhoidectomy and was subsequently discharged. 

The medical records indicate the patient has a diagnosis of gastrointestinal (GI) bleed in the setting of Von Willebrand disease (VWD), history of gastrointestinal angiodysplasia, external hemorrhoids, mitral valve prolapse, seborrheic dermatitis, and vestibular migraines. The patient presented to the emergency room (ER) with complaints of dizziness and recent GI bleeding. 

While in the emergency room (ER) the patient was found to have a hemoglobin of 6.1 and tachycardia at 123. During admission, the patient underwent a blood transfusion, a colonoscopy and an esophagogastroduodenoscopy (EGD). The patient also underwent a hemorrhoidectomy and was discharged. 

Per a denial letter, the claim is made that a physical examination was unremarkable and that the patient was hemodynamically stable. However, that is not accurate as the patient had a heart rate greater than 120 and vital signs such as heart rate are a part of the physical exam as thus is a remarkable finding. Also, tachycardia above 120 qualifies as hemodynamic instability and it suggests the patient has had significant blood loss. Blood pressure has shown to be the first vital sign that presents abnormal prior to death, as it relates to bleeding. Furthermore, the patient has Von Willebrand's Disease (VWD) which puts the patient at high risk for uncontrolled bleeding due to an inability to form clots. As such, the patient required urgent attention to find the source of bleeding and thus prevent continued blood loss and risk of death.      

"Gastrointestinal (GI) bleeding is an important cause of morbidity and mortality in von Willebrand disease (VWD). It has been noted that GI bleeding caused by angiodysplasia is overrepresented in VWD patients compared to other causes. The bleeding from angiodysplasia is notoriously difficult to treat; recurrences and rebleeds are common. A growing body of basic science evidence demonstrates that von Willebrand factor negatively regulates angiogenesis through multiple pathways. VWD is clinically highly associated with angiodysplasia. The predisposition to angiodysplasia likely accounts for many of the clinical difficulties related to managing GI bleeding in VWD patients. Diagnosis and treatment are challenging with the current tools available, and much further research is needed to further optimize care for these patients with regard to acute treatment, prophylaxis, and adjunctive therapies" (1). 

"Vital signs will start to deviate from normal, tachycardia being the first vital sign to increase (100 to 120 beats per minute), which is followed by an increased respiratory rate (20-24 breaths per minute). Class III hemorrhage is 30 to 40% of total blood volume loss" (2). 

"Von Willebrand disease is a bleeding disorder caused by the qualitative or quantitative deficiency of the pro-von Willebrand factor. Affected people may complain of excessive bruising, prolonged bleeding from mucosal surfaces, and prolonged bleeding after minor trauma" (3). 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is substantiated.