Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hematemesis.
Treatment: Inpatient hospital admission.

The insurer is denied coverage for inpatient hospital admission.  The denial is upheld. 

This female patient has a history of alcohol abuse, heroin abuse, hepatitis C, pancreatitis and cirrhosis who presented to the Emergency Department (ED) with complaints of vomiting dark red blood since the prior night.  The patient reported that she drank 2 pints of alcohol.  The patient has a history of drinking 4 pints of vodka every day for 3 years and using heroin 4 to 7 times daily for 14 years.  The patient was tachycardic in the ED with a heart rate ranging from 100 to 120. Upon assessment, the patient's abdomen was soft, mildly distended and guarded. The treatment plan included cardiac monitoring, intravenous fluids, Protonix, ciprofloxacin, diazepam and Zofran. The patient's lab work was the following: white blood cell (WBC) 15, hemoglobin 8.3, platelets 146, INR (international normalized ratio) 1.3, sodium 132, and lipase 21.  The patient had an episode of hematemesis of 500 milliliters in the ED. Gastroenterology and Critical Care services were consulted.  The patient was admitted to the Medical Intensive Care Unit with a diagnosis of hematemesis with nausea. The patient's hemoglobin decreased to 6.8, and she received a blood transfusion of 1 unit of packed red blood cells.  Treatment also included continuing with intravenous (IV) fluids, IV protein pump inhibitors, methadone, multivitamins, thiamine and folate.  The patient was offered an esophagogastroduodenoscopy, but she declined.  The patient was discharged against medical advice (AMA). The patient's hemoglobin level was 8.5 at discharge.

The patient is a female who had alcoholic liver disease and was vomiting blood. While in the Emergency Room (ER), the patient had an episode of 500cc (cubic centimeters) of hematemesis. The patient's hemoglobin was 8.3 but then subsequently dropped to 6.8. The patient developed thrombocytopenia with the platelet count going down to 64,000. The patient refused an endoscopy.

Clinical indications for admission for Upper Gastrointestinal Bleeding (MCG M-180) include ongoing active bleeding, high risk endoscopic features, variceal bleeding, coagulopathy that is not reversible, peritoneal signs, and anemia associated with signs of cardiac ischemia. In this case, the patient did not meet these criteria.

Clinical indications for Upper Gastrointestinal  Bleeding Observation care (MCG OCG: OC-021) include having a vital signs abnormality, active bleeding suspected, symptomatic anemia, and the need for an endoscopy prior to discharge to an outpatient setting. In this case, the patient met these criteria.

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. The patient had upper gastrointestinal (GI) bleeding and was suspected active bleeding, but not variceal bleeding. The patient required a transfusion and an endoscopy.  However, this level of care is consistent with the observation care criteria and not with the acute care criteria, as noted above.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.