Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 

The determination is upheld. 

The patient presented to the emergency room (ER) with anemia findings on labs at the primary medical doctor's (PMD's) office and complaints of bleeding per rectum about 4-5 months prior, occurring 2-3 times per week. About 2 days prior to arrival, the patient developed non-bloody non-bilious (NBNB) vomiting times (x) 2 episodes. The PMD recommended that the patient's father bring her to the ER. The father reported that she has been slightly tired and appeared to be pale. The patient denied dizziness, a headache, chest pain, a cough, fever or diarrhea. 

She presented to the ER tachycardic and pale. On exam in the ER she was described to be well hydrated but pale appearing. Her temperature (T) was 98.7 degrees Fahrenheit, pulse was 97, respiratory rate (RR) 20, blood pressure (BP) 110/60, and oxygen saturation (O2 sat) 100%. A complete blood count (CBC) showed a hemoglobin and hematocrit (H/H)of 7.0/25.0, mean corpuscular volume (MCV) 61 and platelets (PLT) 143. Her stool was also found to be guaiac positive. Hematology and gastroenterology (GI) were both consulted. Both agreed she most likely had iron deficiency anemia. 
The patient was then admitted to the floor for a transfusion and further work up for the bleeding cause. While on the floor, patient received a 1 unit (U) transfusion of packed red blood cells (PRBCs) and the hemoglobin (Hgb) subsequently increased to 9.8. The physician notes documented the patient was tachycardic in the 130s but this resolved into 70s after the transfusion. Hematology suggested to start her on iron three times per day (TID) with no further work up. GI recommended additional labs such as stool for ova and paracites (O&P), stool culture, Helicobacter (H.) pylori, immunoglobulin (Ig)A, endomysial antibodies and repeat complete blood count (CBC) /C20 and clotting factors which were drawn. She was also started on Protonix daily. An endoscopy and colonoscopy were recommended for the patient per GI and the patient was started on a bowel prep and made nothing by mouth (NPO) prior to the procedure. She tolerated procedure well with no issues. She was found to have ulcerative proctitis during the procedure and biopsies were taken. She was started on Rowasa enemas nightly. The patient was given one enema prior to discharge and sent home on iron daily, Pepcid twice daily (BID) and Rowasa enemas nightly. She was instructed to follow up with GI in 1 week and Hematology in 2 weeks. 

At issue is the medical necessity of an inpatient stay. 

The requested health service/treatment of inpatient stay was not medically necessary for this patient. 

This patient presented with hemodynamically significant anemia. At the time of presentation, she appeared pale and was tachycardic. Her history was significant for a 4-5 month history of intermittent blood seen when stooling, wiping and in the toilet. She was treated with a blood transfusion and her tachycardia resolved. She did not have any signs of active or critical GI bleeding at the time of presentation. Her microcytic anemia along with her history was more indicative of iron deficiency anemia from chronic blood loss. There was no current melena reported or bright red blood per rectum. There was no report of coffee ground or fresh blood in her emesis. She was not reported to have any mental status changes or orthostatic hypotension. After the transfusion, she was deemed stable as evidenced by stable vital signs, recovered hemoglobin level and no signs of active bleeding, she could have safely been managed at a lower level of care with close follow up. An endoscopy and colonoscopy could have been scheduled for a later date and did not need to be performed emergently as an inpatient. An inpatient stay was not medically necessary for this patient.