Digestive system
Inpatient hospital

Diagnosis: Vomiting
Treatment: Inpatient hospital
The insurer denied the inpatient stay. The health plan's determination is overturned.

The patient is a female with medical history of diverticulosis complicated by diverticulitis, osteoarthritis with chronic nonsteroidal anti-inflammatory drug use, cancer status post mastectomy, and two gastric ulcers. She presented to the emergency department with five days of melena and coffee-ground emesis, epigastric pain, lightheadedness, and dyspnea. She had been taking ibuprofen and meloxicam. Vital signs were notable for heart rate of 107/minute. Physical examination was notable for pale conjunctiva and a soft, non-distended abdomen with epigastric tenderness. Labs showed low hemoglobin of 7.0 and hematocrit of 22.1%, and elevated alanine aminotransferase of 42. She was briefly hypotensive in the emergency department. She was transfused with a unit of packed red blood cells. She was treated with intravenous pantoprazole. She was made nil per os (NPO) and admitted to the hospital.

The inpatient level of care is medically necessary. In this case, the patient presented with melena, coffee ground emesis, anemia, and symptoms of anemia. She had recent active gastrointestinal bleeding and significant anemia concerning for an upper gastrointestinal tract bleeding source such as inflammation (esophagitis, gastritis, duodenitis, peptic ulcer disease), or arteriovenous malformations. She had close monitoring, which was warranted as bleeding can be severe and sudden in onset. Additionally, her blood count continued to decline, and she had a poor response to blood transfusion, requiring a second blood transfusion two days after presentation. Given the risk of recurrent bleeding and hemodynamic decompensation, discharge within two days after presentation would not have been appropriate, and the inpatient level of care is supported.