Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia.
Treatment: Inpatient admission.
The insurer denied coverage for an inpatient admission.
The denial is upheld.

According to the medical records, the patient is a female with pre-existing diagnoses of hypertension, hyperlipidemia, atrial fibrillation on chronic anticoagulation, and asthma. She came to the emergency room (ER) with progressively worsening shortness of breath, chest tightness, dyspnea on exertion, and weakness in the setting of low blood count. Her labs showed a hemoglobin of 5.8. Her vitals were significant for a respiratory rate of 22. The patient was started on 2 units of packed red blood cells (PRBCs) in the ER. She was admitted for further management of symptomatic anemia. The patient remained stable and was discharged after treatment. 

"Transfusion may also be indicated in patients with active or acute bleeding as well as in patients with symptoms related to anemia (for example, tachycardia, weakness, dyspnea on exertion) and hemoglobin less than 8 g (grams)/dL(deciliter). Unless the patient is actively bleeding, it is recommended to transfuse 1 unit of packed red cells at a time, which will typically increase the hemoglobin value by 1 g/dL and hematocrit by 3%. Follow up by checking post-transfusion hemoglobin." (Lotterman, S. et al. 2021).

"The American Association of Blood Banks published in the Journal of the American Medical Association new clinical practice guidelines for red blood cell (RBC) transfusion thresholds and storage. Based on a review of 31 randomized clinical trials (comprising 12,587 participants) in which patients were randomized to receive transfusion at either restrictive thresholds (transfusion not indicated until the hemoglobin level of 7-8 g /dL or liberal thresholds 9-10 g/dL), the guidelines recommend more restrictive transfusion thresholds for adult patients: Transfusion is not indicated until the hemoglobin level is 7 g/dL. This 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). These more restrictive thresholds were not associated with higher rates of adverse clinical outcomes, including 30-day mortality, myocardial infarction, cerebrovascular accident, rebleeding, pneumonia, or thromboembolism." (AABB (American Association of Blood Banks) Releases Clinical Practice Guidelines on Red Blood Cell Transfusion and Storage 2016).

"Transfusion of blood products is one of the most common medical procedures, used for patients with a wide range of medical conditions to improve tissue oxygenation, achieve hemostasis, and/or fight infections. Moreover, transfusion therapy enables many complex procedures, such as organ transplantation, cardiac and other surgeries, and stem cell transplantation. Yet the curriculum of academic medical and nursing programs provides limited exposure and training towards helping providers to understand the attributes of the different types of blood products, appreciate the risks of transfusion, and raise awareness of the accumulating body of evidence that is helping to refine our understanding of clinical indications for each type of transfusion." (A Compendium of Transfusion Practice Guidelines 2021).                                                         

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for a hospital admission is upheld. Medical Necessity is not substantiated.