Diagnosis: Symptomatic anemia

Treatment: Inpatient hospital admission

The insurer denied coverage inpatient hospital admission. The denial was reversed.

This patient is a male with a past medical history of morbid obesity, hypertension, hyperlipidemia, atrial fibrillation, diabetes mellitus, and asthma. The patient was sent to the Emergency Department by his primary care physician for low hemoglobin of 5.3. The patient stated that he had been feeling tired for the last few months. The patient had noticed a decrease in appetite. The patient had no significant loss of weight. There was no history of dark-colored stools or blood in the stools. The patient complained of shortness of breath on exertion for the last few months. The patient underwent a rectal examination, which revealed guaiac-negative stool. The patient had never undergone a colonoscopy. The laboratory studies revealed a white blood cell (WBC) count of 10.6, a hemoglobin of 5.5, a hematocrit of 17.7, a mean corpuscle volume (MCV) of 76.4, a blood urea nitrogen (BUN) of 16, a creatinine of 2.0 and an iron level of 29. The patient was admitted with a diagnosis of symptomatic anemia. During the hospitalization, the patient was given a total of three units of blood and received daily intravenous ferric gluconate. The patient underwent an esophagogastroduodenoscopy (EGD) revealing gastritis and a duodenal ulcer. The patient was discharged home and was to follow-up as an outpatient.

The requested services were previously denied. The denial was based on MCG 23rd edition: Anemia, Iron Deficiency, or Unspecified ORG: M-35 (ISC) inpatient admission.
The healthcare plan did not act reasonably or with sound medical judgment or in the best interest of the patient. The inpatient hospital admission is considered medically necessary for this patient.

The patient had several severe comorbid factors including hypertension, hyperlipidemia, atrial fibrillation, morbid obesity, diabetes, and renal insufficiency. He presented with severe symptomatic anemia of unclear etiology. The most common cause of this presentation is gastrointestinal bleeding. This was confirmed on endoscopy in this patient. Although he was not found to be actively bleeding at presentation, this clinical profile of the patient is associated with increased issues in gastrointestinal (GI) bleed. It was essential to correct severe anemia in a controlled manner, perform a GI work up and if this was negative, do a hematologic work up. These tests could not have been done as an outpatient. With so many serious possibilities and comorbidities requiring immediate addressing, observation status is inappropriate. Inpatient admission was medically necessary.

The carrier's denial of coverage for the inpatient hospital admission is reversed. The medical necessity is substantiated.