Abdominal/Stomach Pain
Inpatient Hospital

The patient is a male with history of thoracic aortic aneurysm status/post (s/p) repair, metallic aortic valve placement on home anticoagulation, and current marijuana abuse who presented to the emergency department (ED) with episodes of bright red blood per rectum associated with abdominal pain. Hemodynamics were stable. The international normalized ratio (INR) was 2.1 while on coumadin. He was admitted to inpatient level of care for ongoing work up and management of his presenting complaint with hemodynamically stable lower gastrointestinal (GI) bleed.

The health plan's determination is overturned in part. The inpatient health services are medically necessary with the patient's baseline comorbidities including psychiatric illness, aortic valve replacement and need for anticoagulation and presenting complaint of lower GI bleed with broad differential diagnosis. Initially infectious colitis was suspected based on the CT abdomen requiring IV antibiotics and then ischemic colitis was seen based on the colonoscopy. This required careful serial abdominal exams, reinitiating of diet and anticoagulation with Lovenox bridging with monitoring for further bleeding and serial complete blood count (CBC).
However, the patient could have been discharged on the 4th day after all the necessary procedures, and consults were done. The patient was stable hemodynamically with no further bleeding in the prior three days.