Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vaginal Bleeding

Treatment: Inpatient hospital stay

The insurer denied coverage for inpatient hospital stay.

The denial is overturned.

According to the medical records, the patient is a female with history of menorrhagia, colostomy status post reversal, fibroids, and hypertension, who presented to the emergency room (ER) with severe anemia weakness and fatigue. She came with complaints of a three-week history of vaginal bleeding and weakness. Two units of packed red blood cells (PRBC) were transfused. Hematology noted that hgb (hemoglobin) level improved from 3.5 to 5.1. Plan was to transfuse 2 more units. They recommended administering intravenous (IV) iron. The patient left the hospital against medical advice (AMA).

"Hemoglobin thresholds and triggers for blood transfusions have changed over the years moving from a higher to a lower level. This review article summarizes the current evidence of transfusion thresholds in the hospitalized as well as in the outpatient setting and particularly in myelodysplasia. Fatigue is the main reported symptom in this group of patients and current clinical trials are looking for a more liberal approach of red cell transfusion and the effect on quality of life as opposed to the restrictive strategy used in the critical care setting. Practical considerations, the cost effectiveness of this strategy in addition to the possible complications, and the use of quality of life questionnaires have also been reviewed." (Koutsavlis, I. (2016)

"Blood transfusions are a relatively common medical procedure and while typically safe, there are multiple complications that practitioners need to be able to recognize and treat. This activity reviews the indications for blood transfusion, including for special patient populations, the pre-transfusion preparation and the potential complications of blood transfusions. This activity highlights the role of the interprofessional team in caring for patients undergoing blood transfusions." (Lotterman, S., Sharma, S. 2021)

"The transfusion of red cell concentrates (RCC) is indicated in order to achieve a fast increase in the supply of oxygen to the tissues, when the concentration of haemoglobin (Hb) is low and/or the oxygen carrying capacity is reduced, in the presence of inadequate physiological mechanisms of compensation." (Liumbruno, G. et al. 2009)

Criteria are met in that the patient had a diagnosis of iron deficiency anemia, Hct (hematocrit less than 30, and feeling weak and fatigues, which is same as "feeling dizzy or faint" expressed differently. 

This patient had severe life-threatening, symptomatic anemia and needed to be transfused further. Keeping her inpatient to transfuse 2 more units would have been appropriate and her signing out AMA has no bearing on the medical necessity of the admission.

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

The hospital stay is considered medically necessary for this patient.                                                          

The insurers denial of coverage for the hospital stay is overturned. Medical necessity is substantiated.