Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectal bleeding and Chronic anemia.  
Treatment: Inpatient hospital admission. 

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

This is a female patient with chronic anemia, who was brought to the Emergency Room (ER) with rectal bleeding.  The patient's physical exam showed a heart rate (HR) of 75 and blood pressure (BP) of 107/71.  On evaluation, the patient's hemoglobin was 6. The patient was complaining of epigastric pain.  The patient was given 2 units of packed red blood cells (PRBC) and was admitted.  The patient's iron studies showed evidence of iron deficiency.  The patient was kept nothing by mouth (NPO) status but had no further gastrointestinal (GI) bleeding.  The patient became combative due to schizophrenia and required a sitter.  The patient's hemoglobin improved and she was discharged with outpatient follow-up.

Per Roubinian et al. (2019), "From 2010 to 2014, the prevalence of moderate anemia (hemoglobin levels between 7 and 10 g/dL [grams per deciliter]) at hospital discharge increased from 20% to 25%...nd [red blood cell (RBC)] transfusion declined by 28%...The proportion of patients whose moderate anemia had resolved within 6 months of hospital discharge decreased from 42% to 34%...and RBC transfusion and rehospitalization within 6 months of hospital discharge decreased from 19% to 17% and 37% to 33%, respectively...during this period, the adjusted 6-month mortality rate decreased from 16.1% to 15.6%...in patients with moderate anemia, in parallel with that of all others."

Per Carson et al. (2016), "It is good practice to consider the hemoglobin level, the overall clinical context, patient preferences, and alternative therapies when making transfusion decisions regarding an individual patient.  Recommendation 1: a restrictive [red blood cell (RBC)] transfusion threshold in which the transfusion is not indicated until the hemoglobin level is 7 g/dL is recommended for hospitalized adult patients who are hemodynamically stable, including critically ill patients, rather than when the hemoglobin level is 10 g/dL (strong recommendation, moderate quality evidence).  A restrictive RBC transfusion threshold of 8 g/dL is recommended for patients undergoing orthopedic surgery, cardiac surgery, and those with preexisting cardiovascular disease (strong recommendation, moderate quality evidence).  The restrictive transfusion threshold of 7 g/dL is likely comparable with 8 g/dL, but [randomized clinical trials (RCT)] evidence is not available for all patient categories.  These recommendations do not apply to patients with acute coronary syndrome, severe thrombocytopenia (patients treated for hematological or oncological reasons who are at risk of bleeding), and chronic transfusion dependent anemia (not recommended due to insufficient evidence).  Recommendation 2: patients, including neonates, should receive RBC units selected at any point within their licensed dating period (standard issue) rather than limiting patients to transfusion of only fresh (storage length: <10 days) RBC units (strong recommendation, moderate quality evidence)."               

Based on review of the medical record, this patient presented with one episode of rectal bleeding with evidence of chronic anemia.  The patient was otherwise hemodynamically stable.  The patient could have been safely managed at an alternative level of care such as observation as opposed to acute level care.  Therefore, the inpatient hospital admission was not considered medically necessary for this patient.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. 
                                          
The carrier's denial of coverage for the inpatient hospital admission should be upheld.  The medical necessity is not substantiated.