201908-120182
2019
Fidelis Care New York
Medicaid
Digestive System/ Gastrointestinal
Inpatient Hospital
Medical necessity
Upheld
Case Summary
This is a patient with a medical history of chronic obstructive pulmonary disease on home oxygen, hypertension, paroxysmal atrial fibrillation on Eliquis, transient ischemic attack, ischemic cerebrovascular accident, gastrointestinal bleeding, and heavy tobacco abuse. She presented to the emergency department with dyspnea, gradually increasing for 6 weeks. Her dyspnea was mild, increased with walking or exertion and improved with rest. Vital signs were notable for a low diastolic blood pressure of 41 millimeters of mercury (mmHg). A computed tomography scan of the abdomen and pelvis showed moderate cirrhotic contour of the liver with a 12 millimeter (mm) enhancing lesion in the right hepatic dome, and 11 mm enhancing lesion in the left hepatic lobe, possibly consistent with hepatocellular carcinoma; magnetic resonance imaging was recommended for evaluation; there were findings consistent with chronic inflammatory changes in the ascending colon and proximal transverse colon, mild diverticulosis, myomatous uterus, mild cellulitis in the lower abdominal wall, and mild anasarca.
She was admitted and placed on telemetry. The health plan's determination is upheld. The patient presented with gastrointestinal bleeding and anemia but did not have tachycardia or persistent hypotension. No cause for inpatient status, such as severe intra-abdominal process, obstruction, perforation, abscess, or toxic megacolon, was suspected or apparent on imaging. The patient had monitoring of clinical status, vital signs, serial labs, imaging, and a Gastroenterology consultation, which were warranted, given history of cardiovascular disease and the potential for ischemia if bleeding resulted in inadequate perfusion. An endoscopy was performed. No severe complications of cirrhosis, such as acute decompensation or hepatic encephalopathy or variceal bleeding, were found. Eliquis, the anticoagulant the enrollee was taking, is not clearly associated with gastrointestinal bleeding, and has a half-life of approximately 12 hours. As hemodynamic status remained stable, and there was no hypotension or hemodynamic decompensation, all of the measures that were undertaken, including labs, monitoring, endoscopy, blood transfusion, and specialist consultations, could have been performed at a lower level of care without the inpatient level of care.