Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission.  
The denial was upheld. 

The patient is a female with a past medical history significant for end-stage renal disease on hemodialysis, anemia of chronic disease, and hypertension who presented to the emergency department with painless rectal bleeding. The patient noticed the bleeding several hours before the presentation when she had a bowel movement. The patient described it as a dark stool with blood clots mixed with some red blood. The patient said that she had a similar episode years back, and at that time she underwent an esophagogastroduodenoscopy (EGD). According to the patient, she was told that she had stomach ulcers but could not remember if she was treated for helicobacter (H.) pylori infection.
The review of systems was obtained on admission. It was negative for fever, chills, abdominal pain, distention, appetite changes, dysuria, and shortness of breath. Her vital signs were a temperature of 98.2F, heart rate was 65 beats per minute (bpm), respiratory rate was 18, blood pressure was 156/60, and oxygen saturation was 99%.
The patient was in no acute distress. The lung exam was unremarkable. The heart exam was within normal limits. The abdomen was soft, nontender, nondistended, without guarding or rebound. There was no evidence of peritonitis. The patient had a fistula in the left upper extremity with palpable thrill. There were no open wounds. There was no evidence of infection.
Her white blood cell count was 11.1, hemoglobin was 9.9, and platelets were 256. Her sodium was 133, potassium was 5.0, chloride was 93, bicarbonate was 26, blood urea nitrogen (BUN) was 33, creatinine was 7.78, and glucose was 82. Her liver function tests were unremarkable. A computed tomography (CT) scan of the abdomen and pelvis revealed a cystic lesion in the body of the pancreas.
The patient was admitted to the hospital with lower gastrointestinal bleeding. The admitting physician indicated a CT angiogram of the abdomen was negative for active bleeding. The patient was hemodynamically stable and had no tachycardia. The patient was kept nothing by mouth (NPO), and her hemoglobin was checked every 6 hours.
During the hospital stay, the rectal bleeding decreased. The patient had an episode of hyperkalemia, which was treated. The patient received hemodialysis, and post dialysis labs were stable.
The patient did not want to finish inpatient workup; therefore, she was discharged home in stable clinical condition with a recommendation to follow up with surgical oncology.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination of medical necessity is upheld in whole.

The inpatient hospital stay was not medically necessary for this patient.
The review of the medical records demonstrated that the patient's lower gastrointestinal bleeding was not associated with hemodynamic instability, acute cardiac ischemia, or arrhythmias of immediate concern. There was no evidence that during the hospital stay the patient underwent any evaluation or treatment requiring admission at the acute inpatient level of care.
Even though the patient had hyperkalemia, it was indicated that the blood specimen was hemolyzed, therefore this number was not accurate. A patient with chronic kidney disease might experience hyperkalemia, which is generally tolerated well.
The review of the medical records demonstrated that the patient had no other medical conditions that would justify an inpatient stay. Even though the patient had a pancreatic mass found on the CT scan of the abdomen, there were no procedures or treatments performed in the hospital to evaluate this further. The patient's hemoglobin stabilized, and she was discharged home in stable clinical condition.
Overall, she remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. Therefore, the inpatient hospital stay was not medically necessary for this patient.