Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for chronic obstructive pulmonary disease (COPD), asthma, seizures, cerebrovascular accident (CVA), congestive heart failure, hypertension, and diabetes mellitus, who presented to the emergency department with complaints of rectal bleeding that had been going on for 1-2 weeks.  The patient stated that she had a history of hemorrhoids and had been pushing the hemorrhoids back in.  She reported bright red blood in the toilet every time she moved her bowels.  The patient had no other complaints and denied headaches, dizziness, chest pain, abdominal pain, nausea, vomiting, weakness, fever, or chills.
On the physical exam, the patient was afebrile, her blood pressure was 162/85, she had a respiratory rate of 18, a pulse rate of 94, and an oxygen saturation of 95% on room air.  The patient was in no acute distress. Her head, eyes, ears, neck, throat (HEENT) exam was within normal limits and her cardiovascular exam was unremarkable.  The respiratory exam revealed equal rising chest with some expiratory wheezing but no rales or rhonchi.  There was no increased work of breathing.  The abdominal exam was unremarkable.  The rectal exam revealed no fissures.  The patient had small non-thrombosed hemorrhoids, a brown stool was noted without melena or bright red blood. The rest of the physical exam was unremarkable.
A chest x-ray was completed, which showed no radiographic evidence of acute cardiopulmonary disease.
The patient was admitted to the hospital with a diagnosis of rectal bleeding that was attributed to external hemorrhoids.  Another admitting diagnosis was a COPD exacerbation.  It was mentioned that the patient had mild wheezing bilaterally.  The patient was ordered intravenous corticosteroids, bronchodilators, and antibiotics.  The rest of the chronic medical conditions were stable.
During the hospital stay all of the patient's symptoms resolved, and she was discharged home with a recommendation to follow up with a surgeon in regard to the treatment of her hemorrhoids.
The health plan's determination is upheld.
The main clinical problem, while the patient was admitted to the hospital, was rectal bleeding, which was attributed to hemorrhoids.
The rectal bleeding was subacute and did not lead to significant anemia or hemodynamic instability.  The patient did not require any surgical interventions to be performed in the hospital that would necessitate an admission at the acute inpatient level of care.
Another critical problem that was reported in the chart was a COPD exacerbation, since the patient complained of shortness breath.  The review of the medical records did not demonstrate that the patient had any evidence of respiratory distress, significant hypoxemia, hypercapnia requiring the use of invasive or noninvasive means of mechanical ventilation.
The patient's COPD exacerbation was very mild and did not justify an admission at the acute inpatient level of care.  In general, mild exacerbations often can be treated on an outpatient basis in patients with adequate home support.
Taking into consideration all of this information, there is no overwhelming evidence that any of the clinical conditions mentioned at the time of admission justified an evaluation and treatment at the acute inpatient level of care.  Care could have been provided at a lower level.