Diagnosis: Iron deficient anemia
Treatment: Full hospital admission

The insurer denied coverage for full hospital admission. The denial is upheld.

This patient is a male with a history of iron deficient anemia and gastrointestinal (GI) bleeding. He had a previous gastric sleeve operation. He had received 5 units of PRBC prior to being transferred to this hospital. During this hospitalization there was no report of active bleeding. He remained hemodynamically stable. The plan was for a double balloon enteroscopy. The hemoglobin was 9.2. The double balloon enteroscopy did not reveal a source of the bleeding in the small intestine but showed blood in the cecum. A colonoscopy was then performed and no evidence of bleeding was found. The hemoglobin remained stable.

Clinical indications for admission for iron deficient anemia (M-35) include hemodynamic instability, active bleeding, altered mental status, syncope, cardiac arrhythmia, severe thrombocyctopenia, acute renal failure and cardiac ischemia. The patient did not have these conditions.

This patient had iron deficient anemia and now required further workup including a double balloon enteroscopy and colonoscopy. He was not actively bleeding at this time and the workup did not find a source for the bleeding. He remained stable to have had both procedures performed on an outpatient basis. No further transfusions were needed during this hospitalization. He did not meet MCG criteria for admission for anemia and he was not having active bleeding. The healthcare plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. The denial is upheld.

Based on the above, the medical necessity for the full hospital admission is not substantiated. The insurer's denial is upheld.