Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gingival Bleeding. 
Treatment: Hospital admission. 
The insurer denied coverage for the hospital admission. 
The denial is overturned. 

This is a patient that was admitted to the hospital with gingival bleeding. The patient was treated with intravenous (IV) Rocephin, Vitamin K, and otherwise with eye drops. The patient's platelet (PLT) count was 27 and there was a concern about possible gastrointestinal (GI) bleeding. During this admission, the patient was seen and evaluated by Gastroenterology. 

The patient received Tylenol by mouth (PO), Potassium Chloride (KCL) 40 milliequivalent (meQ) PO, Vitamin K PO, Corgard PO, Lactulose PO, Lasix 20 milligrams (mg) PO, Calamine/zinc suspension topically, Timoptic eye drops, Restasis eye drops, and magnesium sulfate IV. 

The patient's labs showed his hemoglobin and hematocrit (H&H) to be 11.5 and 32.3, PLT was 31, white blood cell count (WBC) was 3.8, potassium (K) was 3.3, chloride (Cl) was 111, carbon dioxide (CO2) was 20.8, calcium (CA) was 7.9, total protein (TP) was 5.8, albumin (Alb) was 2.8, total bilirubin (T bili) was 1.6, aspartate aminotransferase (AST) was 5, prothrombin time (PT) was 17.6, international normalized ratio (INR) was 1.4 and activated partial thromboplastin time (aPTT) was 40.8. 

The provider noted on the discharge summary "GI was consulted, determined the anemia likely chronic and not due to a GI bleed. The recommendation was to start ciprofloxacin. Hematology was consulted, and recommended giving Vitamin K orally for three days." 

The request is for hospital admission which is under review. 

As previously stated, the patient was admitted to the hospital with gingival bleeding. The patient was treated with intravenous (IV) Rocephin, Vitamin K, and otherwise with eye drops. The patient's platelet (PLT) count was 27 and there was a concern about possible gastrointestinal (GI) bleeding. During this admission, the patient was seen and evaluated by Gastroenterology. 

The clinical situation warranted an admission because of significant uncertainties in diagnosis, severe thrombocytopenia, and possible GI bleeding. Once GI ruled out a GI bleed and determined that anemia and thrombocytopenia are chronic, discharge was appropriate. 

"Implementation of a multidisciplinary protocol for management of acute GIB was associated with earlier intervention, fewer packed red blood cells (PRBC) transfusions, shorter hospital length of stay, and fewer readmissions with gastrointestinal bleeding (GIB). Future research should seek to establish causal relationships between communication practices and outcomes" (Loftus, T. J., et al 2017). 

"A broad spectrum of diseases can cause anemia and thrombocytopenia. Some of these diseases are a hematological emergency; others are benign diseases, so early and accurate diagnosis is crucial in managing such patients. Usually, iron deficiency anemia (IDA) is associated with thrombocytosis or normal platelets; however, in rare cases, IDA can be associated with thrombocytopenia; even though, thrombocytopenia that occurs with IDA responds to iron therapy. Iron therapy rarely causes transient thrombocytopenia per se. We are reporting an African female patient who is found to have thrombocytopenia secondary to IDA, and she responded to iron replacement therapy initially with a transient drop in platelets, followed by a rapid rise in platelets till platelets reached the normal level" (Eisa, M. S., et al 2021). 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for hospital admission is substantiated.