Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rectal bleeding
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a male patient who presented to the emergency department with concerns of rectal bleeding for several months. The pertinent history included chronic gastrointestinal bleeding with a prior colonoscopy and endoscopy that were unremarkable. 
The initial examination documented the patient as alert and oriented without significant abdominal findings. An electrocardiogram (EKG) was relatively unremarkable. A computed tomography (CT) scan of the abdomen/pelvis was relatively unremarkable. The admitting physician documented that it was unclear why the patient came to the hospital given the issues had been present for over several months. The initial impression included chronic rectal bleed, pancytopenia, alcohol abuse (current Clinical Institute Withdrawal Assessment (CIWA) of 0), transaminitis, and elevated lactate. The treatment plan included intravenous fluids, proton pump inhibitors, CIWA monitoring, an abdominal ultrasound, and obtaining extensive outside records.
Gastroenterology consulted and had an impression of a rectal bleed possibly due to diverticulosis versus internal hemorrhoids versus other anorectal pathology. Recommendations were to advance the diet as tolerated, intravenous fluids, additional laboratory testing, and an endoscopy when medically optimized. In addition, it was noted the CIWA (Clinical Institute Withdrawal Assessment) score was 10. A transfusion was unable to be performed overnight due to a persistent low-grade fever, the maximum temperature (Tmax) was 100.9 degrees Fahrenheit (F). A dark stool was noted. He was also noted to be actively withdrawing. Gastroenterology recommended an esophagogastroduodenoscopy (EGD) due to melena and anemia requiring a transfusion. An EGD revealed gastric erosions and erythematous mucosa. Seizure-like activity was noted with a postictal state. Benzodiazepines were provided and then scheduled. The antibiotics were completed. The patient was discharged. At issue is the medical necessity of an inpatient admission.

Based on the clinical documentation provided, evidence-based literature, and standards of care, acute inpatient level of care was medically necessary for the entire admission.

The patient had a history of rectal bleeding and alcohol abuse and presented with rectal bleeding. The treatment plan included intravenous fluids, serial Hgb (Hemoglobin) monitoring, and consultations. Following observation care, the Hgb continued to trend down with observed melena. An esophagogastroduodenoscopy (EGD) was performed which revealed gastric erosions. A total of three units of packed red blood cells were transfused. The hospital course was further complicated by an alcohol withdrawal syndrome with associated elevated CIWA (Clinical Institute Withdrawal Assessment) scores and ultimately a witnessed seizure. The clinical indications for admission to inpatient care were met. The patient had ongoing active bleeding evident by a decreasing hematocrit with observed melena requiring the transfusion of three units of packed red blood cells. In addition, the patient had signs of withdrawal that persisted despite observation care and progressed to a seizure.[2][3]