Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastrointestinal Bleeding
Treatment: Inpatient Hospital
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient has a medical history of chronic hemorrhoid disease with bleeding, prediabetes, and remote tuberculosis. He presented to the emergency department with dizziness, palpitations, dyspnea on exertion, and one week of diarrhea with hematochezia above baseline. The diarrhea had resolved prior to presentation, but the hematochezia had continued. He had been taking aspirin. Vital signs were notable for a pulse rate of 57 beats per minute. The physical examination was notable for a soft, nontender abdomen. Lab results showed a low hemoglobin of 4.4 grams per deciliter (g/dL) and hematocrit of 15.4%, low sodium of 135 millimoles per liter (mmol/L), and low iron of 6 micrograms per deciliter (ug/dL). He was treated with intravenous pantoprazole. He was transfused with 2 units of packed red blood cells. Subsequent lab results showed an increased hemoglobin of 5.6 g/dL and hematocrit of 18.4%. A gastroenterology consultation concluded that he had no active bleeding, lab results consistent with iron deficiency, and likely a diverticular bleed that had now resolved with differential diagnoses including hemorrhoids, arteriovenous malformations, malignancy, and peptic ulcer disease; the recommendation was for an esophagogastroduodenoscopy and colonoscopy, pantoprazole 40 milligrams (mg) daily, regular diet, transfuse to maintain hemoglobin over 7 g/dL, follow blood count, maintain large-bore intravenous (IV) access, and monitor vital signs.
At issue is the medical necessity for the inpatient level of care. 
The acute inpatient level of care was medically necessary.
The patient presented with reported lower gastrointestinal bleeding, severe anemia, and lack of appropriate response to significant blood transfusion after presentation. Additionally, he was on aspirin, which increased the risk for protracted bleeding, and the potential that bleeding would become rapid and result in sudden decompensation. The bleeding source was suspected to be diverticular bleeding or hemorrhoids but was not definitively established. He had no complaints, and denied chest pain, dyspnea, palpitations, abdominal pain, nausea, vomiting, fever, and chills. Lab results showed a low hemoglobin of 7.9 g/dL and hematocrit of 24.4%. He was transfused with 2 units of packed red blood cells. He had bloody bowel movements mixed with stool, with gradually decreasing bleeding; he denied chest pain, dyspnea, dizziness, lightheadedness, presyncope, abdominal pain, nausea, vomiting, and diarrhea. He was hungry and denied chest pain, abdominal pain, nausea, vomiting, diarrhea, dyspnea, dizziness, and lightheadedness. He had 2 episodes of watery bloody bowel movements with bowel preparation, multiple episodes of vomiting which limited his bowel preparation, as well as 7 beats of ventricular tachycardia on telemetry. He had an output of water mixed with blood during bowel preparation. An esophagogastroduodenoscopy showed a normal esophagus, irregular Z-line, normal stomach, and normal duodenum. A colonoscopy showed a 10 millimeter (mm) sigmoid colon polyp which was removed with snare cautery, diverticulosis in the descending colon, and non-bleeding internal hemorrhoids; no active source of bleeding was identified.
This patient had visible ongoing gastrointestinal bleeding. 
Close monitoring and resuscitation were warranted. [1-5]. An esophagogastroduodenoscopy and colonoscopy examined the gastrointestinal tract, and there was no further hematochezia on  and lab results showed a low hemoglobin of 8.2 g/dL and hematocrit 27.2%. He was discharged with a plan for gastroenterology and primary care follow-up.
The inpatient stay was medically necessary.