Diagnosis: vaginal bleeding.
Treatment: inpatient admission.
The insurer is denied coverage for inpatient admission
The denial is upheld.

This female patient has a history of diabetes mellitus, hypertension, hyperlipidemia, obesity, fibroids, polyps, and abdominal myomectomy currently taking iron pills for a consistently low blood count. A recent transvaginal ultrasound was positive for 2 centimeters (cm) and 3 cm fibroids. She presented to the Emergency Room (ER) with complaints of vaginal bleeding for the prior 2-4 days. The patient reported that due to her fibroids, her periods normally lasted 10 days and were heavy, but not to this extent. She was prescribed norethindrone 2 weeks prior but stopped taking it 4 days prior to presentation. She was scheduled to see her Gynecologist that morning but felt dizzy, had palpitations and her Gynecologist instructed her to go to the ER. Examination revealed normal vital signs and gross blood pooling in the vaginal vault with small clots. Review of prior lab results showed a hemoglobin result in the 11-12 range. A hematocrit (HCT) done in the ER was 26.9 and a repeat HCT was 23.6. The patient was admitted and received two units of packed red blood cells. Eight hours post transfusion her HCT was 27.4, bleeding was minimal, and she was discharged.

The patient presented to the ER with complaints of vaginal bleeding and dizziness. Her medical history was significant for anemia and uterine fibroids. On admission to the ER the patient had normal vital signs with a normal blood pressure and pulse. She exhibited no signs of dizziness or syncope. Her abdominal and pelvic examinations were normal except for a 16 week sized uterus on palpation, and documentation of evidence of moderate active vaginal bleeding. There was no evidence of hemodynamic instability. The patient was noted to be alert, awake and oriented during admission and inpatient care. The patient was appropriately observed and given IV(intravenous) fluids in the ER with resolution of reported dizziness. Her condition was stable on presentation and during admission. She had no significant underlying medical conditions increasing her risk for complications to indicate inpatient admission. She did not require IV or narcotic pain medication. There was no evidence of significant infection or acute/ongoing hemorrhage which could have indicated inpatient admission. Therefore, there is no evidence in the medical records that the patient required inpatient admission. The patient's condition could have been managed in an outpatient setting, including administration of packed red cells. She could have been observed and given the supportive care she received in the ER or in an intermediate care unit. Follow up care could then be performed as was planned at her discharge. Therefore, the inpatient admission was not medically necessary.


The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is upheld. The medical necessity is not substantiated.