Diagnosis: Heavy Vaginal Bleeding, Dizziness And Shortness Of Breath.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with a diagnosis of uterine fibroids and anemia. On presentation, she was found to have a hemoglobin of 5.7. She was transfused with 1 unit PRBCs (packed red blood cells) and transferred to Brookdale for a higher level of care.

The patient was admitted with a diagnosis of symptomatic anemia for transfusion and potential hysterectomy. The patient remained clinically stable. She was given 2 units of packed RBCs (red blood cells), and her repeat hemoglobin was 8. Her symptoms of lightheadedness resolved. Repeat hematocrit after transfusion has remained stable. The patient signed out AMA (against medical advice) and left the hospital.

No, while the blood transfusion was appropriate, the Inpatient admission was not medically necessary.
This patient was symptomatic. In addition, she fulfills the transfusion guidelines for use of blood components: her hemoglobin was less than 8g/dl (grams per deciliter). As such, transfusion was appropriate.

In this day and age, transfusions are done routinely in outpatient settings (oncology clinics, infusion centers, even at home). So the need for transfusion is not a reason for admission.

The transfusion was started at the originating facility. The transfusion could have been completed at a lower level of care without the need for admission. Following transfusion, the patient could have been monitored, her CBC (complete blood count) repeated and then discharged home with a follow-up within 24 hours with her primary physician or gynecologist. Nothing was done in the hospital that could not have been done as an outpatient.

The clinical indications for inpatient care for patients with anemia include active massive hemorrhage, active hemolysis, cognitive impairment, tachycardia, orthostatic changes, heart failure, chest pain, syncope. The patient was stable and did not have any of the above indications for admission.

Based on all of the above, admission was not medically necessary. The patient could have been treated at the observation level of care.

The health plan's decision was appropriate, as the inpatient admission was not needed to manage this patient.