Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Missed abortion, Anemia 

Treatment: Inpatient admission

The insurer denied coverage for the inpatient admission.

The denial is upheld. 

This is a female patient with a past medical history of anemia who presented to the Emergency Department (ED) with complaints of vaginal bleeding. The patient stated that she recently had a medical abortion and she had not stopped bleeding vaginally since that time. The patient complained of abdominal cramping, shortness of breath, a headache and weakness. The patient also stated that she had went to her gynecologist and had bloodwork done. The patient's ultrasound had revealed that a sac was still present. The patient was informed by her gynecologist that her hemoglobin was around 6, and that she needed to go to the ED for further work up. The patient's vital signs on ED presentation were: temperature 98, blood pressure 134/80, heart rate 102, respiratory rate 18, and oxygen saturation 99% on room air. The patient's bloodwork included a white blood cell count of 9.37, red blood cell count of 2.46, and hemoglobin of 6.6 and hematocrit of 20.9. A transvaginal ultrasound was performed and the impression was hypervascular retained products of conception within the endometrial cavity. The patient was diagnosed with a missed abortion and a secondary diagnosis of anemia. The patient was admitted.  The treatment plan included a blood transfusion of 1 unit of packed red blood cells and a dilation and suction curettage procedure. The patient's repeat hemoglobin was 7.4. Postoperatively, the patient was hemodynamically monitored, and was treated with intravenous hydration and pain management. The patient was discharged in stable condition on day 2 of admission with outpatient instructions to follow-up with the Obstetrics and Gynecology specialist.

Based on the review of the medical record, this patient was actively bleeding and she underwent a dilation and curettage (D&C) procedure. A D&C is an ambulatory procedure.  Since the patient's hemoglobin was low, the patient was transfused with 1 unit of packed red blood cells. The patient fulfilled the transfusion guidelines for use of blood component. The patient's hemoglobin was less than 8 and she was symptomatic, so transfusion was medically necessary. However, blood transfusion is not a sufficient medical indication for inpatient admission.

As per the Milliman Care Guidelines (MCG) guidelines for anemia, the clinical indications for inpatient level of care include: active massive hemorrhage, active hemolysis, cognitive impairment, tachycardia, orthostatic changes, heart failure, chest pain, syncope. In this case, this patient did not have any of these clinical indications for inpatient level of care.  Following the D&C procedure, the patient's bleeding was minimal, and the patient's hemoglobin level was responsive to transfusion and was improved. The patient could have been discharged after finishing her transfusion and ascertaining that her hemoglobin level was stable. The patient could have been transfused and observed in the recovery area, where her complete blood count (CBC) would have been repeated there.  Neither a D&C procedure nor a need for transfusion required inpatient level of care. Thus, inpatient admission was not medically necessary for this patient.

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

The carrier's denial of coverage for the inpatient admission should be upheld. The medical necessity is not substantiated.