Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Thrombocytopenia

Treatment full hospital admission

The insurer denied coverage for full hospital admission

The denial is upheld

The patient has a past medical history notable for ulcerative colitis (treated with steroids, methotrexate and vedolizumab), colitis and thrombocytopenia x (times) 4 months that was referred to the Emergency Department for assessment and management of thrombocytopenia. The drop in platelets appeared to coincide with the use of methotrexate. The last platelet count was 36. The manifestation of the low platelets included lower extremity bruising and intermittent petechiae. Her last methotrexate dose was 1 day prior and her last vedolizumab was 1 week prior. Her vitals were notable for Temperature 98.2 Fahrenheit, Heart Rate 104, Respiratory Rate 24, Blood Pressure 105/60 and oxygen saturation of 100% (percent) on room air. Her physical exam was notable for bruises over both anterior shins and scattered petechiae on her forearms. Her admitting weight was 16.3 kilograms. Admitting laboratories were notable for white blood count 16.7, hemoglobin 10.8, C-Reactive Protein 0.6 and Erythrocyte Sedimentation Rate 11. Stool for Clostridium difficile and Gastrointestinal pathogens were negative. Nasal washings were negative for COVID-19 (Novel 2019 Coronovirus), Influenza and Respiratory Syncytial Virus.  No Imaging was performed.  The decision was to admit the patient for evaluation of "worsening thrombocytopenia". During her admission her methotrexate was stopped and her platelet counts rose daily. The patient was evaluated by hematology who concluded that the thrombocytopenia was drug related and sent laboratories to rule out immune-mediated thrombocytopenia. The patient also had crampy abdominal pain with defecation and some bright red blood per rectum during the hospitalization without a drop in hemoglobin that led to an upper endoscopy and flexible sigmoidoscopy which were notable for mild to moderate active colitis. The patient was discharged home on the same day on her same medications without methotrexate for outpatient follow-up.  She remained afebrile with stable vitals and no additional symptoms throughout the admission.
 
This child appeared to have chronic (months) drug-induced thrombocytopenia secondary to methotrexate. Her presenting symptoms were not acute and had been present on and off for months. She had no dangerous bleeding or need for blood transfusions to justify an acute care setting. Methotrexate was discontinued during the admission but her weekly oral administration was not due to be dosed for days. Her platelet count on admission was rising not dropping from the outpatient value days prior.

According to a review of the approach to children with thrombocytopenia from UpToDate (see attached pdf file) the authors note the following:

"Thrombocytopenia, defined as a platelet count <150,000/microL (microliter), is clinically suspected when a child develops characteristic clinical symptoms, which include a petechial rash, easy bruising or bleeding, or mucosal hemorrhage. Thrombocytopenia is often asymptomatic and may present as an incidental finding during routine evaluation or during laboratory investigations performed for other reasons."

This patient had thrombocytopenia with modest recurrent symptoms. There was never hemodynamic, physical exam findings or laboratory evidence of serious bleeding to merit inpatient evaluation and management. The hematology evaluation could have been performed in the outpatient setting efficiently and safely without risk to the patient.

This patient commonly developed active colitis symptoms during her management on her current medications. The upper endoscopy and flexible sigmoidoscopy could have been performed more appropriately in the ambulatory setting rather than in the acute inpatient setting. No change in management occurred following her inpatient endoscopic procedures that were performed as an inpatient for the convenience of the medical team. In conclusion, the assessment and management of this patient's recurrent, improving thrombocytopenia did not merit the acute inpatient setting (not medically necessary) and was performed for convenience rather than for medical acuity. This decision was rendered based on review of the hospital record and the references cited above.

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

Based on the above, the medical necessity for the full hospital admission is not substantiated. The insurer's denial is upheld.