Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectal Bleeding
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history of Crohn's disease status/post (s/p) ileocolonic resection on vedolizumab who presented to the emergency room with rectal bleeding. He had been seen at another facility a few days prior for similar symptoms and a bleeding source was not identified on computed tomography (CT) angiogram and colonoscopy. He was hemodynamically stable and afebrile. He had pallor but the rest of physical examination was normal. He was anemic with a hemoglobin of 5.7 grams per deciliter (g/dl) and had mild hypokalemia. The rest of his lab results were unremarkable. He was admitted as inpatient and transfused with 2 units of packed red blood cells (PRBCs). Gastroenterology was consulted and did an esophagogastroduodenoscopy (EGD) which did not reveal a bleeding source in the upper gastrointestinal (GI) tract. A colonoscopy revealed a bleeding angioectasia in the neo-terminal ileum which was cauterized and treated with a hemostatic clip. He had no further bleeding and remained hemodynamically stable throughout his hospitalization. He was discharged to home with outpatient follow up.
The requested health service/treatment of inpatient stay was not medically necessary for this patient.
This patient had no evidence of hemodynamic instability and had a benign abdominal examination without peritoneal signs. Therefore, he could have been managed at a lower level of care rather than acute inpatient level of care and discharged to home once he was able to tolerate oral nutrition and medications. As many as 15-25% of patients with inflammatory bowel disease may require hospitalization related to a flare of their disease. The goals of hospitalization are to assess disease severity, exclude infection, administer rapidly acting and highly effective medication regimens, and determine response. During hospitalization, patients should be given venous thromboembolism prophylaxis and monitored for the development of toxic megacolon. Patients who do not respond to intravenous corticosteroids should be considered for rescue therapy with infliximab or other biological agents. Patients who do respond to medical therapies should be discharged on an appropriate maintenance regimen when they meet discharge criteria.
Lower GI bleeding (LGIB) is diagnosed in 20 percent (%) to 30% of all patients presenting with major GI bleeding. The annual incidence of LGIB is 0.03%, and is predominantly seen in patients between the second to eighth decades of life. Approximately 35.7 per 100,000 adults in the United States are hospitalized for LGIB annually. Although blood loss from LGIB can range from trivial to massive and life-threatening, the majority of patients have self-limited bleeding and an uncomplicated hospitalization. In contrast to patients with acute upper GI bleeding (UGIB), patients with LGIB tend to present with a higher hemoglobin level and are less likely to develop hypotensive shock or require blood transfusions. The mortality rate ranges from 2% to 4% and usually results from comorbidities and nosocomial infections. The most common causes of LGIB are diverticular bleeding, ischemic colitis, angioectasia, hemorrhoids, colorectal neoplasia, postpolypectomy bleeding, inflammatory bowel disease, infectious colitis, nonsteroidal anti-inflammatory drug (NSAID) colopathy, radiation proctopathy, stercoral ulcer, rectal varices, Dieulafoy lesion. By using the predictors of heart rate greater than (>) 100 beats/minute, systolic blood pressure less than (<) 115 millimeters of mercury (mmHg), syncope, nontender abdominal examination, rectal bleeding during the first 4 hours of evaluation, aspirin use, and multiple comorbid illnesses, patients may be stratified into 3 distinct risk categories. Patients with >3 factors are at a high risk of severe bleeding (80%), those with 1 to 3 risk factors are at moderate risk (45%), and those with no risk factors are considered low risk (10%). An initial hematocrit of < 35%, the presence of abnormal vital signs (systolic blood pressure < 100 mmHg or heart rate >100 beats/minute) 1 hour after initial medical evaluation, and gross blood on initial rectal examination are independent predictors of severe LGIB.