Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrointestinal Bleeding

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient presented to the hospital.  The patient had a history of diabetes mellitus, hypertension, hypothyroidism status post thyroidectomy, obesity status post gastric bypass, and iron deficiency anemia.  The patient complained of left flank pain and buzzing in the right ear.  The patient denied dysuria/hematuria.  Vital signs noted temperature of 99.1 Fahrenheit, heart rate of 70, respirations of 20, blood pressure of 151/106, and oxygen saturation of 99% on room air.  Laboratory results noted hemoglobin of 6.1, hematocrit of 22.6, and platelet count of 290.  A computed tomography (CT) of the patient's abdomen and pelvis showed punctate non-obstructing right renal stone.  The patient was admitted for further work-up of gastrointestinal bleed.  There was a plan for 2 units of red blood cells.  Reevaluation with rectal exam showed positive guaiac stool.  The patient had a history of negative endoscopy but was unable to get colonoscopy secondary to retained stool.  There was a plan for upper endoscopy.  The patient had hypokalemia that was treated with intravenous (IV) potassium x3 doses.  The upper endoscopy showed normal esophagus.  The patient was to follow-up with gastroenterology for colonoscopy after discharge.  The patient was deemed appropriate for discharge.

It was argued by the hospital that the hospital admission was medically necessary and supported by the clinical documentation. Considering the patient's comorbidities, multiple risk factors, significant presenting symptoms of concern, and the abnormal findings during the emergency department evaluation period, admission to evaluate and treat was medically necessary.

Per the cited references, admission to the hospital may be indicated for gastrointestinal bleeding when there is hemodynamic instability, ongoing active bleeding, when mechanical ventilation is necessary, when there is peptic ulcer with high risk endoscopic features, when there is coagulopathy that is not quickly reversible, when there is anemia that requires inpatient admission with the presence of tachycardia, altered mental status, heart failure, chest pain, dyspnea, or other findings suggestive of inadequate perfusion when observation care treatment with transfusion or volume replacement is judged to be inappropriate or has been ineffective, when there is gastric outlet or bowel obstruction, when there are peritoneal signs, or when there is inability to maintain oral hydration. 

In this case, the patient presented to the hospital with complaints of abdominal pain.  It was argued that the hospital admission was medically necessary and supported by the clinical documentation.  Due to acute flank pain and acute symptomatic anemia concerning for acute symptomatic gastrointestinal bleed, the patient was deemed unstable for discharge.  However, the documentation did not identify hemodynamic instability that did not respond to observation level of care treatment, there was no documentation of peptic ulcer with high risk endoscopic features, coagulopathy that was not quickly reversible, or that the patient's anemia required inpatient admission with the presence of tachycardia, altered mental status, heart failure, chest pain, dyspnea, or other findings of inadequate perfusion when observation care treatment with transfusion failed.  There was no documentation of gastric outlet or bowel obstruction, peritoneal signs, or inability to maintain oral hydration.  Thus, the patient's care could have been completed at a lower level such as observation.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for a hospital admission is not substantiated.