Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a female patient with a history of chronic back pain who presented to the emergency department due to acute back pain. During a follow-up visit with the orthopedist one week before admission, her pain management regimen was changed to Ibuprofen 600 mg Milligram three times a day and a Medrol Dosepak. However, she discontinued both medications abruptly due to abdominal discomfort.
On the day of admission, the patient experienced a severe episode of abdominal and back pain, leading to the dispatching of Emergency Medical Services (EMS) services. She was transported to the hospital for further evaluation. A fecal occult blood test (FOBT) was positive. A computed tomography (CT) scan of the abdomen/pelvis identified an 11.3 centimeter (cm) enhancing mass lesion at the fundus of the gallbladder. In the ER (emergency room), the patient received treatment, including a 500 cubic centimeter (cc) bolus of normal saline, morphine, and Zofran.
During the review of systems, the patient reported abdominal and back pain as positive findings. The rest of the review of systems yielded negative results.

The patient was admitted to the hospital with a suspicion of gastrointestinal bleeding, leading to a gastroenterology consultation. Additionally, she was found to have a gallbladder mass, prompting consultation with the surgical service. Chronic back pain was also diagnosed, and pain medications were initiated.
During her hospital stay, the patient's hemoglobin further dropped to 6.1 g/dL gram/deciliter, and she received a transfusion of 1 unit of packed red blood cells. She was prescribed Protonix 40 mg intravenous (IV) twice daily and received IV iron for a low iron level.
Initially, she refused an esophagogastroduodenoscopy (EGD)/colonoscopy but later consented, and the EGD revealed two non-bleeding ulcers. The hemoglobin remained stable after the transfusion. At issue is the medical necessity of an inpatient stay.

The inpatient hospital stay was medically necessary for this patient at the acute inpatient level of care.
The patient presented to the hospital with abdominal and back pain and was diagnosed with anemia. Even though the anemia was not associated with significant hemodynamic instability, there was evidence of active bleeding based on the fact that the patient's hemoglobin went down to the point when the patient required a transfusion of packed red blood cells.
It was clear that the patient was experiencing acute gastrointestinal bleeding that was triggered by the use of nonsteroidal anti-inflammatory drugs (NSAIDs) as well as corticosteroids before her admission. The gastrointestinal bleeding also manifested in heme-positive stools.
Taking into consideration all of this information, the patient should have been admitted to the hospital for close monitoring for signs of hemodynamic instability, endoscopic studies to identify the bleeding sores, and continued monitoring of hemoglobin and hematocrit to determine the need for transfusion of packed red blood cells. The admission at the acute inpatient level of care was reasonable, given the presence of anemia with likely acute gastrointestinal bleeding.