Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission
The denial is upheld.

The patient is an adult female with a request for acute care. The patient has a history of reflux, anxiety, asthma, and abdominal aortic aneurysm. The patient had a prior admission to the hospital due to a hemoglobin of 5.5. She received transfusion, colonoscopy, and esophagogastroduodenoscopy (EGD). She had polyps and diverticulosis detected. There is a history of peripheral vascular disease with angiogram is pending. There is history of iron deficiency anemia.

The patient's physician sent the patient to the emergency room because of the low hemoglobin assessment prior to the angiogram of the lower extremity. The angiogram was canceled. There was no bleeding, no vomiting, no vaginal bleeding, no pain, no dizziness, no lightheadedness, and no shortness of breath. The blood pressure was 105/69, pulse 73, temperature was normal, and oxygenation was 97%. There was no abnormality of physical exam. A rectal exam showed no active bleeding, stool for occult blood was negative, and there were no neurologic deficits. The hemoglobin was 6.5 and the patient was admitted to the hospital for further evaluation of iron deficiency anemia. The electrolytes and renal function were normal, liver test was normal, prothrombin time was normal, white blood cells (WBCs) were normal, platelets were normal, mean corpuscular volume (MCV) and red cell distribution width (RDW) were consistent with iron deficiency. The next day, the patient received an iron infusion and blood transfusion. Her hemoglobin was 7.8.

On day #2, the patient's abdominal x-ray showed mild fecal impaction. There was no obstruction, no fever; her hemoglobin was 8.2. The team was planning for esophagogastroduodenoscopy and colonoscopy the next day. The patient had a large bowel movement, felt better, with less bloating, and no vomiting.

On day #3, esophagogastroduodenoscopy and colonoscopy showed ectasia in the stomach that was coagulated. Colonoscopy was limited due to preparation. There was diverticulosis and redundant mucosa. A push enteroscopy was described at the time of the esophagogastroduodenoscopy with no abnormality of the duodenum or jejunum. The one stomach ectasia was five millimeters with no bleeding. Coagulation to prevent bleeding was performed with the argon plasma coagulator. The patient received an iron infusion; hemoglobin was improved to 8.0. She was medically stable and discharged home.

The proposed inpatient hospital admission was not medically necessary.

This patient had an unexplained iron deficiency anemia. However, there was no active bleeding and no hemodynamic instability. Once the initial evaluation in the emergency room showed negative stool for occult blood, no reported bleeding, no chest pain, no shortness of breath, no pre-syncope, and no dizziness, the patient did not require acute hospitalization to further evaluate iron deficiency anemia. The patient was admitted to the hospital for convenience of performing an esophagogastroduodenoscopy and colonoscopy at a later date. Reflective of the patient's clinical stability was that the esophagogastroduodenoscopy and colonoscopy were not performed until three days later. Once they were completed the patient was discharged home.