Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient stay. 
The denial was overturned in whole. 

The patient is a male with a history of (h/o) end stage renal disease (ESRD) on hemodialysis (HD), severe cardiomyopathy with an automatic implantable cardioverter defibrillator (AICD), and smoking, who presented to the emergency department (ED) with a low hemoglobin (Hgb) of 5.6 grams (g)/deciliter (dl). He recently was admitted to the hospital with anemia from a gastrointestinal (GI) bleed but left against medical advice (AMA) without getting an esophagogastroduodenoscopy (EGD) and colonoscopy. He developed dizziness and lightheadedness. He was sent to the ED from the dialysis center when he was found to have a Hgb of 5.6 g/dl.
In the ED he was hypotensive with a blood pressure (BP) of 85/53. His labs showed a Hgb of 5.6, troponin was 0.032 and Pro brain (or B-type) natriuretic peptide (BNP) of greater than (>) 50,000. He refused a rectal exam. He was given 2 packed red blood cells (PRBC) and intravenous (IV) proton pump inhibitors (PPI). He was admitted with a plan to see gastrointestinal (GI) as he was willing to consider an endoscopy. He underwent an EGD. His Hgb stabilized after the PRBC transfusion. He was subsequently discharged home.
At issue is the medical necessity of an Inpatient stay.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Inpatient Stay was medically necessary for this patient.
This is a patient with significant comorbidities, but most importantly he has severe cardiomyopathy, and his anemia was severe that in the setting of severely depressed ejection fraction does increase the risk of mortality. It was important to identify and correct the underlying etiology and observe him in the inpatient setting. He was recently admitted to the hospital with a GI bleed and anemia, but he refused an EGD and colonoscopy and left against medical advice. He was found to have a low Hgb. A Hgb less than (<) 6.5 is considered moderate to severe and can be life threatening. [1] In the ED he was hypotensive with a BP of 85/53. He refused the rectal exam. However, the concern for blood loss anemia was high due to his recent history of a GI bleed.
GI evaluated the patient who recommended an EGD. The patient's severe cardiomyopathy made him a high-risk patient as severe anemia with severely diminished ejection fraction increases the morbidity and mortality. Anemia and iron deficiency are important and common comorbidities that often coexist in patients with heart failure. Both conditions, together or independently, are associated with poor clinical status and worse outcomes. [2] Therefore, correction of anemia and the evaluation in the inpatient setting was critical as the patient presented with a critically low Hgb in the setting of severely diminished ejection fraction. The correction of source of bleeding and stability of Hgb without any active bleeding was important and appropriate. [2]
Therefore, the requested health service/treatment of Inpatient Stay was medically necessary.