Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vaginal Bleeding	

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is overturned.

This is the case of a male to female transgender person, with history of gender reassignment surgery. The patient presented to the Emergency Department (ED) with complaints of vaginal bleeding. The patient used a dilator after reassignment surgery. The bleeding site was packed, and a transfusion was needed as well as intravenous (IV) potassium.

Per noted, the patient had active bleeding with clots with inability to visualize the bleeding source, but no external laceration/lesion. The patient had a pad with 100 cubic centimeter (cc) of blood/clots, and upon removal of clot in introitus, there was a moderate amount of active bleeding in vaginal canal, unable to find source of bleeding due to narrow vaginal canal. Speculum was not able to be used. Labs indicated hemoglobin (Hgb) and hematocrit (Hct) of 10.5/31.9, and potassium of 3.2. Initial ED treatment included a liter of normal saline, potassium chloride intravenous piggyback (IVPB), gynecology consult, vaginal packing with Surgicel, TXA (tranexamic acid) IV, and type and hold for four units of packed red blood cells (PRBC).  Repeat labs showed Hgb as 9.2, and Hct as 27.2.

It was noted that packing was soaked with blood, as well as pelvic pad. With speculum source of bleeding was identified and appeared to be slowly oozing. Vaginal packing placed, as well as foley catheter. Additionally, it was noted the patient received two units of PRBCs.

The patient had active vaginal bleeding that required packing, and two units of PRBC to treatment the acute blood loss. In addition, the source of the vaginal bleeding could not be identified. Later, the source of the bleeding was able to be visualized and determined to be slowly oozing. Later in the day, the bleeding was assessed and was determined to not be actively bleeding. Based on Hgb and Hct, the patient required a transfusion. After the transfusion, the patient was noted to be able to be discharged. 

Therefore, the patient required inpatient admission with monitoring of labs and vitals with transfusions as well.

"Although there are different levels of evidence and variable degrees of recommendations, almost all scientific societies recommend the implementation of a restrictive red blood cell (RBC) transfusion policy (hemoglobin levels ranging between 6 and 8 g/dL [grams per decilitre]) in surgical, hemodynamically stable patients. However, the appropriateness of RBC transfusion at higher hemoglobin levels should be evaluated case by case, considering acute ongoing blood losses, comorbidities, signs of organ ischemia and symptoms indicative of hypoxia. In any case, published guidelines, including those dealing with transfusion therapy in neonatology, generally agree that RBC transfusion is not beneficial when the hemoglobin concentration is greater than 10 g/dL." (Franchini et al 2017)

The health care plan did not act reasonably and with sound medical judgment or in the best interest of the patient.

The transfusion enabled the claimant to be discharged, but it only took place on the same day as discharge. It would not have been safe to discharge before the transfusion.      

The inpatient admission was considered medically necessary for this patient.

The insurer's denial of coverage for the inpatient hospital admission is reversed. Medical necessity is substantiated.