Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastrointestinal bleeding. 
Treatment: Inpatient stay. 

The insurer denied Inpatient stay.  The denial is overturned. 

The patient is a male with medical history of aortic stenosis status post transcatheter aortic valve replacement, aortic dissection repair, atrial fibrillation, hypertension, hyperlipidemia, benign prostatic hyperplasia, and obstructive sleep apnea. He presented to the emergency department with daily gastrointestinal bleeding characterized by maroon-colored stool for four days, sharp left-sided chest pain, and dyspnea. He had been changed from Coumadin to Eliquis a week prior. He had been admitted after presenting with gait abnormalities; he had been diagnosed with a small cerebrovascular accident. 

Vital signs were unremarkable. Physical examination was notable for soft, nontender, nondistended abdomen with normal bowel sounds; rectal exam showed maroon-colored stool, strongly guaiac-positive, without active bleeding. Labs showed low hemoglobin of 12.6 grams per deciliter (g/dL) and hematocrit of 38.2%, elevated blood urea nitrogen of 39 milligrams per deciliter (mg/dL) and otherwise unremarkable comprehensive metabolic panel, normal international normalized ratio, and normal troponin I. Chest x-ray showed no acute abnormality. He was treated with intravenous pantoprazole. Gastroenterology consultation concluded that he had lower gastrointestinal bleeding, currently stable with a wide differential diagnosis, and multiple medical problems including atrial fibrillation and aortic dissection; the recommendation was to hold Eliquis, Cardiology consultation to discuss alternative anticoagulants, clear liquid diet, serial blood count, and consideration of endoscopy and colonoscopy, which the patient declined, and Neurology consultation if endoscopic procedures were planned. Eliquis was held. 

He remained anxious and declined endoscopic procedures. Labs showed low hemoglobin of 12.7 g/dL and hematocrit of 37.9%, and unremarkable comprehensive metabolic panel. He had severe anxiety and delirium. Labs showed low hemoglobin of 13.5 g/dL and normal hematocrit. He had no reported complaints. He was discharged on Lovenox, clonazepam, mirtazapine, quetiapine, and pantoprazole, with a plan for Primary Care, Cardiology, Gastroenterology, Neurology, and Geriatric Psychiatry follow-up. At issue is the medical necessity for the inpatient level of care. 

The inpatient stay is supported as medically necessary for the duration of the stay. In this case, the patient presented with gastrointestinal bleeding and chest pain with dyspnea, in the setting of recent cerebrovascular accident. Close monitoring was warranted as bleeding can be severe and sudden in onset, and he reported melena (the day after presentation) [1-5]. Additionally, the patient had cerebrovascular disease with history of stroke, with risk for myocardial infarction, cerebrovascular accident, and other complications in the event of re-bleeding and anemia [6,7]. He did develop alteration in mental status, including delirium, which warranted monitoring and evaluation as it can be associated with cerebrovascular accident [8]. When delirium had resolved, discharge became appropriate. For these reasons, the inpatient level of care is supported during the duration of the stay.